Public Comment Submission
The public comment period was closed on July 11, 2008. You may view the comments submitted online and via e-mail.
Anonymous on 7/9/2008 2:42:29 PM
The North American Spine Society Exercise Task Force has reviewed the musculoskeletal health section of the document, and would like to commend the Advisory Committee on a very comprehensive review of the existing literature. NASS supports the draft report as written and looks forward to reviewing the subsequent evidence-based guidelines when available.
Anonymous on 7/7/2008 1:23:33 PM
I am a registered dietitian working as the nutritionist on the eating disorder team. I applaud both the efforts of the committee and resulting report. I would request that you include the issue of compulsive and excessive exercise and the connection with eating disorders.
Lee A Roach MS RD
Please address compulsive exercise and eating disorders
Anonymous on 7/1/2008 4:43:34 PM
June 30, 2008
Dear Secretary Leavitt,
The Washington Health Foundation (WHF) and its Healthiest State in the Nation Campaign is honored to provide comments on the Department of Health & Human Services Physical Activity Guidelines for Americans.
The Healthiest State in the Nation Campaign promotes personal responsibility for health, and builds collective action around health through leadership and support of collective action toward better public and private health policy. Today, the Healthiest State Campaign is the largest civic engagement project for health in the state history—so far involving more than 1,000 organizations, 35,000 individuals and 400 schools.
Communicating with all these people and organizations has given WHF a good understanding of the public sentiments regarding health issues, and how these issues contribute to Washington's place as the 10th healthiest state in the nation (as determined in the 2008 Healthiest State Report Card released on June 13th).
The Healthiest State Campaign and our Report Card are designed around 12 key health measures and five key health outcomes. Our interest in the HHS Physical Activity Guidelines relates to our Physical Activity measure.
First, thank you for putting so much time and effort into this report and for bringing physical activity to the forefront of our national health debate.
We strongly support any movement that safely encourages physical activity, particularly when it allows people to find their own comfort zone. There is no "one size fits all" plan, and we believe it is important to engage as many people as possible by emphasizing a simple philosophy: Just get started and the improvement will come over time.
Too often, we find physical activity plans that are filled with daunting workout schedules that leave the average person unwilling to take those first steps on the road toward better health. This is an opportunity, at the national level, to provide people with the resources and support we have put in place for the people of Washington state.
We developed an innovative website, www.HealthiestState.org, with a host of free tools allowing Washingtonians to set goals and track their progress in areas such as exercise, nutrition, water intake, and sleep. We also maintain a national website with similar tools at www.HealthiestState.net.
In 2005, we hosted our state's first Governor's Health Bowl, a six-week physical activity challenge. Washingtonians logged one million miles of health on our website that first year. In the 2007 Governor's Health Bowl, we generated more than five million miles of health. That is equivalent to going to the moon and back—ten times!
At the same time, it is important to recognize that policies, in many cases, create a significant barrier for people seeking to increase their physical activity. National progress, as well as advancement in our own state, will depend on the success of changing policies in government, communities and businesses that remove these barriers.
For several years now, we have led an incredibly successful health improvement campaign with a major emphasis on physical activity. Based on both our history and our experience, we believe the key ingredient to any successful physical activity campaign is making it accessible to the average person. Give them a reason to get involved. Help them get off the couch and out of the house without feeling overwhelmed. Create goals that seem achievable.
Further information on the Healthiest State Campaign, including our full policy agenda, is available at our website at www.HealthiestState.org.
Thank you again for the contributions you are making to our understanding of health, and for bringing much needed attention on physical activity and overall health.
President & CEO
Washington Health Foundation
600 Stewart Street
Seattle, WA 98101
Anonymous on 6/29/2008 6:57:00 AM
Anonymous on 6/22/2008 7:11:22 AM
I send you the results and conclusion of my clinicaly cintrolled trials, presented on WCPD 2008, helsinki, Finland as contribution to your Physical Activity recommendations aimed at people at high risk for T2DM.
A proposal - a measure in the modern concept of type-2 diabetes (T2DM) prevention focused on increasing cardiorespiratory fitness and macronutrient content of diet at high-risk obese adult and elderly population
Simovska Vera., MD., PhD.
HEPA Macedonia National organization for the promotion of health-enhancing physical activity, Skopje, Macedonia, FYR
Obesity is known to lead to many health issues: metabolic complications that increase the risk for development of type-2 diabetes (T2DM) in adult and elderly population ("elderly diabetes"), cardiovascular diseases, and joint public health problems.
Our objectives were to promote preventive-therapeutic programmes with a proposal - a measure for increasing cardiorespiratory fitness (VO2max) and macronutrient content of diets intended for obese adult and elderly population with abdominal fat distribution who are asymptomatic, but at high-risk for development of T2DM.
Within the clinically controlled trial at a group of 82 middle-aged subjects (24-65 years) divided into two intervention groups: physical activity and diet (PAD) and diet (D) with mean BMI = 32.6 kg/m2 and present pre-diabetes (a fasting plasma glucose of 100 – 140 mg/dl after an overnight fast), the following were applied: individually dosed, programmed physical activity (PA) and moderate energy reduced diet, performed into two phases.
A proposal - a measure for increasing VO2max with aim to reduce T2DM risk included: 30 minutes daily in 3 bouts of ten minutes or 2 bouts of 15 minutes of moderate-intensity physical activity (3.0 - 4.5 METs for male; 2.1 - 4.2 METs for female) with training pulse of 50 - 59% heart rate maximum reserve in the first phase or 45 - 60 minutes, 3 times a week of moderate to vigorous intensity physical activity (4.5 - 7.0 METs for male; 4.2 - 6.3 METs for female) with training pulse of = 60% heart rate maximum reserve in the second phase. Muscle strength and flexibility exercise was included twice a week.
In the first phase of the research, moderate energy reduced diet had a character of "a temporary" diet of 1200kcal/d with a specific macronutrient content: CHO=50.1% (Poly CH=47.2%), P=25.7% and F=25.8% of total energy intake, a specific relation among SFA, MUFA, PUFA, a low atherogenic potential (AI < 15) and vitamin-mineral supplementation. The second phase was the increased energetic value of the diet for 200 kcal/d with next content: CHO=54.1% (Poly CH=58.9%), P=26% and F=21.1% of total energy intake.
Using tables for gross energy expenditure of various physical activity with known energy cost (METs) were chosen different type of physical activity in accordance with initial level of cardiorespiratory capacity (VO2max), also expressed in term of metabolic equivalents (METs).
VO2max was increased for 17.16% in relation to the initial level of cardiorespiratory capacity in PAD group. At this time, there were significantly greater decreases in the PAD group than those in the D group in fasting plasma glucose, as well as in the Hb A1 c, % F and BW kg.
T2DM can be prevented in high-risk truncal obese adult and elderly population using increasing VO2max and specific macronutrient content of diets in accordance with our a proposal - a measure.
I am not able to set-up MY PROFILE on the web from technical reason on your web site.
Kind regards, Vera Simovska, MD., PhD. specialist of sports medicine subspecialist of hygiene nutrition for healthy and sick people and public health E-mail:firstname.lastname@example.org, www.cindi.makedonija.com
Received via e-mail
Dr. Karen K. Lee
Deputy Director of the Bureau of Chronic Disease Prevention and Control at the New York City Department of Health and Mental Hygiene.
We applaud an update of the Physical Activity Guidelines, with more details for different population groups and to effect different health outcomes. However, we also request the following: inclusion of a review and, if possible, recommendations for non-leisure time activities (referred to as "non-exercise activities" in the guidelines) that can be built into people's daily routines- especially stair use, but also walking or biking to work and school, and use of mass transit. Although leisure time activity has actually increased in recent years, work-time activity, transportation activity, and activity in the home have decreased. As we rely more and more on "conveniences" such as cars instead of walking or biking, elevators and escalators instead of stairs, and email instead of getting up to talk with co-workers, we are steadily decreasing the physical activity that should be part of our normal day. Moreover, by relying on external sources of energy rather than our own, we are contributing to the global climate crisis. Activities such as stair climbing have been shown to increase good (HDL) cholesterol and improve cardiovascular health. Climbing at least 20 floors per week was associated with a 20% lower risk of stroke or death from all causes. It has been estimated that two minutes of additional stair climbing per day would burn an extra 5800 kcal per year or 1.6 pounds, enough to mitigate the average weight gain of 1 pound per year in U.S. adults. Evidence also shows that the type of transportation used can result in significantly increased physical activity levels, including biking to work and using mass transportation. Active transportation has also been shown to be associated with improved health outcomes, such as decreased risk of stroke.[6 ]
We therefore ask you to include a review and, if possible, recommendations for non-leisure time activities, especially stair use.
- Brownson, R.C., T.K. Boehmer, and D.A. Luke, Declining Rates of Physical Activity in the United States: What are the Contributors? Annu. Rev. Public Health, 2005. 26: p. 421–43.
- Boreham, C.A.G., W.F.M. Wallace, and A. Nevill, Training effects of accumulated daily stair-climbing exercise in previously sedentary young women. Preventive Medicine, 2000. 30: p. 277-281.
- Zimring, C., et al., Influences of building design and site design on physical activity: research and intervention opportunities. Am J Prev Med, 2005. 28(2S2): p. 186-193.
- League of American Bicyclists. Bike to Work. [cited 2008 July 2]; Available from: http://www.wbwc.org/btww/commutermanual.pdf.
- Wener, R.E. and G.W. Evans, A Morning Stroll: Levels of Physical Activity in Car and Mass Transit Commuting. Environment and Behavior, 2007. 39: p. 1-13.
- Hu, G., et al., Leisure Time, Occupational, and Commuting Physical Activity and the Risk of Stroke Stroke, 2005. 36: p. 1994-1999.
March of Dimes Foundation
Office of Government Affairs
1146 19th Street, NW, 6th Floor
Washington, DC 20036
Telephone (202) 659-1800
Fax (202) 296-2964
RE: Comments on the Physical Activity Guidelines Advisory Committee Report
The 3 million volunteers and 1,500 staff members of the March of Dimes Foundation appreciate the opportunity to submit comments related to the preparation of the first edition of Physical Activity Guidelines for Americans. The March of Dimes is a national voluntary health agency founded in 1938 by President Franklin D. Roosevelt to prevent polio. Today, the Foundation works to improve the health of mothers, infants and children by preventing birth defects, premature birth and infant mortality through research, community services, education, and advocacy. The March of Dimes is a unique partnership of scientists, clinicians, parents, members of the business community, and other volunteers affiliated with 51 chapters in every state and Puerto Rico.
The Foundation's comments focus on physical activity during pregnancy. For the pregnant woman, exercise can ease many common discomforts of pregnancy such as constipation, backache, fatigue, sleep disturbances and varicose veins. Regular exercise may also help prevent pregnancy-related forms of diabetes and high blood pressure. Fit women may be able to cope better with labor and have a faster recovery after delivery.
Our primary recommendation is that the Guidelines be based on the best available science and the current American College of Obstetricians and Gynecologists Committee Opinion 267. Pregnant women should be advised to have a prenatal medical evaluation and develop a physical activity program with their health care provider. The guidelines should also indicate that pregnant women should be informed that certain forms of physical activity are discouraged such as scuba diving, downhill skiing, and contact sports and that exercises requiring individuals to lie flat on their back after the first trimester be avoided. Additionally, the guidelines should specify that a pregnant woman contact her health care provider immediately if she experiences vaginal bleeding or fluid leakage, shortness of breath prior to exertion, dizziness, headaches, chest pain, muscle weakness, calf pain or swelling, decreased fetal movement or contractions during physical activity.
The March of Dimes supports the Advisory Committee Report's call for additional prospective randomized studies on physical activity during pregnancy. The United States Surgeon General recently convened a conference of the leading health care experts from across the country and consistent with the Advisory Committee's report, conference participants identified maternal physical activity as an area where additional research is needed.
The Surgeon General's conference and the 2006 Institute of Medicine Report on Preterm Birth both acknowledged the importance of considering the lifecourse perspective that outlines how maternal health influences fetal and infant health outcomes and can ultimately affect susceptibility to obesity and chronic disease conditions in adulthood. The opportunity to improve maternal, fetal, and infant health outcomes will provide enormous public health benefits and support a strong rationale to emphasize physical activity as an important priority for women of childbearing age and during uncomplicated pregnancies. Recommendations for physical activity need to be communicated through clear, evidence-based health messages, particularly for pregnant women, which supports the necessity for further research in order to provide accurate information.
The March of Dimes applauds the work done by the Physical Activity Guidelines Advisory Committee appreciates the opportunity to submit recommendations on the first edition of Physical Activity Guidelines for Americans. We hope you will embrace our recommendations to improve the health of pregnant women.
American Academy of Orthopaedic Surgeons
American Association of Orthopaedic Surgeons
6300 North River Road
Rosemont, Illinois 60018
The American Academy of Orthopaedic Surgeons (AAOS), representing over 17,000
board-certified orthopaedic surgeons and researchers, welcomes the opportunity
to respond to the U.S. Department of Health and Human Services (HHS)
for comments to the 2008 Activity Guidelines Advisory Committee Report, per the Federal Register announcement on June 20, 2008 (Volume 73, Number 120).
As the preeminent provider of musculoskeletal education to orthopaedic surgeons, the AAOS applauds the decision to seek input from the scientific community on the HHS Activity Guidelines. The AAOS is pleased to see multiple sections in the report comprehensively dedicated to bone health and musculoskeletal conditions. The AAOS is taking strides to promote physical activity and educate the public about the importance of maintaining healthy bones, joints, and muscles. In partnership with the American Academy of Pediatrics, the AAOS has released a public service announcement promoting healthy nutrition and physical activity, including weight bearing exercises, to battle the childhood obesity epidemic. This PSA, along with the other AAOS public relations media, is available at http://www6.aaos.org/About/Pemr/PSA/2008/psa2008.cfm.
As HHS is aware, musculoskeletal conditions are the leading cause of disability in the United States and account for more than half of all chronic conditions in people over 50. In February 2008, the AAOS, in conjunction with the United States Bone and Joint Decade, American Academy of Physical Medicine and Rehabilitation, American College of Rheumatology, American Society for Bone and Mineral Research, Arthritis Foundation, Orthopaedic Research Society, and Scoliosis Research Society, developed a new edition of The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost , available at http://www.boneandjointburden.org. The book is a compendium of musculoskeletal statistics declaring that the annual direct and indirect costs for bone and joint health are $849 billion – 7.7% of the gross domestic product.
Again, the AAOS is pleased to see the inclusion of musculoskeletal health in multiple sections of the HHS Physical Activity Guidelines, including the comprehensive G5: Musculoskeletal Health section as well as G9: Youth; G10: Adverse Events; G11: Understudied Populations, and in the Research Recommendations.
However, the AAOS does have specific suggestions where further research is
needed. While the AAOS was pleased to see that in G9: Youth, question 5
specifically investigates the relationship of bone health to physical activity
and considers age, developmental status, sex, race/ethnicity, and socioeconomic
status as influencing factors, the AAOS would like to suggest the consideration
of these indicating factors, specifically sex and race/ethnicity, in other areas
of research – particularly
osteoporosis, which affects millions of Americans.
The Women's Health Issues Advisory Board (WHIAB) of the AAOS has made strides
to stress the significance of sex- and gender-specific research. For example,
while more women suffer from osteoporosis and hip fractures, men have
significantly higher morbidity and mortality rates after hip fracture. Although
osteoporosis is more commonly seen in women, the burden of osteoporosis in men
remains underdiagnosed and underreported. Furthermore, with regard to racial
little information is available for men. However, with regard to women, the incidence of osteoporotic fractures among African American and Hispanic women is less than that of Caucasian and Asian women, although their risk is still significant. In this regard, the AAOS recommends the following:
- Structural, neuromuscular, and hormonal differences in males and females should be considered when doing research on incidence of injury and bone deterioration related to sedentary behavior or conditions of low bone mass and density such as osteoporosis.
- Sex and gender should be included in the questions in G5: Musculoskeletal Health and specifically stated in the Research Recommendations.
The AAOS is appreciative for the opportunity to provide feedback. If there are questions, please feel free to contact Robert S. Jasak, Esq., AAOS Senior Regulatory Representative, Office of Government Relations, at 202-548-4151 or email@example.com.
With Kind Regards,
Kristy L. Weber, MD
Chair, AAOS Council on Research, Quality Assessment, and Technology
Denis R. Clohisy, MD
Chair, AAOS Research Development Committee
Mary I. O'Connor, MD
Chair, AAOS Women's Health Issues Advisory Board
Carol Crecy, Director
Office of Communications
Administration on Aging/DHHS
Thank you for the opportunity to provide comment on the Report. AoA staff has reviewed the Report and we find it to be very thoughtful and thorough. Our comments, therefore, are few and focus on Part H: Research Recommendations.
Introductory paragraph. "Selected subpopulations, especially various race/ethnic groups, persons of low socioeconomic status (SES), individuals with specific cognitive and physical disabilities, and obese persons.
Recommend changing to read "individuals with specific cognitive and physical disabilities and chronic conditions."
Recommend that research on all of the categories be broken out by gender and race/ethnicity. In addition, 65 plus research needs to be broken up into age and gender subcategories in recognition of the growing life span and the prevalence of women.
Recommendation One. "Uniform data collection is needed with respect to the type of physical activity (e.g., leisure-time, occupational) and physical activity..."
Recommend changing to read "Uniform data collection is needed with respect to the type of physical activity (e.g., leisure-time, occupational, and household activity, including caregiving tasks) and physical activity...."
Research Recommendations of PAGAC Subcommittees
Recommendation one: This should also include Native Americans and Asian/Pacific Islanders as both groups have specific health risks.
Recommendation three: "Further examination of the effects of physical activity on metabolic syndrome and T2D also is warranted to determine whether and how its effect differ in youth and adults."
Recommend changing to: "Further examination of the effects of physical activity on metabolic syndrome and T2D also is warranted to determine whether and how its effect differ(s) in youth, adults, and older adults." Again, older adults should not be bundled with adults. Type II diabetes is increasing in this population.
Recommendation one: "Studies should be stratified by age, functional level, and severity of disability"
Recommend changing to read: "Studies should be stratified by age, gender, functional level, and severity of disability"
National Dairy Council®
[Announcement of the Availability of the Physical Activity Guidelines Advisory Committee Report, and a Public Comment Period Federal Register, June 20, 2008 (Volume 73, Number 120)]
The NATIONAL DAIRY COUNCIL® appreciates the opportunity to provide information that may assist the Department of Health and Human Services in its important work on the Physical Activity Guidelines Committee Report To The Secretary of Health and Human Services.
The NATIONAL DAIRY COUNCIL® is an organization that initiates and administers nutrition research, develops nutrition programs, and provides information on nutrition to health professionals and others concerned about good nutrition. The NATIONAL DAIRY COUNCIL® has been a leader in nutrition research and education since 1915. Through its affiliated Dairy Council units, the NATIONAL DAIRY COUNCIL® is recognized throughout the nation as a leader in nutrition research and education.
The NATIONAL DAIRY COUNCIL® would like to congratulate the Physical Activity Guidelines Advisory Committee (PAGAC) for its work in preparing the report to the Secretary of Health and Human Services. The NATIONAL DAIRY COUNCIL® appreciates the opportunity to provide input to this process and wants to call attention to the point:
- While the report provides a thorough analysis and excellent summation of the role that physical activity plays in health and disease, it does not adequately address the role of nutrition and the synergy between nutrition and physical activity that has been well established by scientific research.
In considering the scientific evidence on physical activity, health outcomes and prevention of chronic disease, it is critical that nutrition be recognized as an integral part of the equation. The synergistic relationship between nutrients, physical activity and several chronic diseases (i.e., osteoporosis, sarcopenia) is well established (1, 2) and it is important that Americans become aware of what the science indicates.
As the 2002 IOM DRI for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids states, one of the most important steps to a healthy diet and lifestyle is to start by "adopting an active lifestyle" (3). It is the challenge of the DHHS to take what is learned from the PAGAC report, integrate what we know about the role of diet, and leverage the two to maximize reductions in chronic disease risk in Americans.
There are only two areas of the PAGAC report that specifically highlight the link between physical activity and diet. In the section on metabolic health, the report states: " The difficulty of evaluating many of the large RCT's looking at the effects of physical activity or exercise on diabetes prevention has been to sort out the effects of diet versus physical activity, as these treatments are commonly combined in large trials (G3-11). " The report also includes a figure and chart that highlight the combined role that physical activity and diet have in weight loss. They show that when combined, weight loss is greater than with either physical activity or diet alone (G4-7). The scientific evidence shows that the synergy that exists between physical activity and diet should be leveraged to reduce the risk for other chronic diseases.
With the aging of our population, sarcopenia has become a major public health focus. Given the estimated prevalence in 30% of individuals over 60 years old (4), as well as the pivotal role of muscle mass in frailty, fall risk, maintenance of Activities of Daily Living (ADLs) and mortality, as laid out in the report, greater efforts are needed to achieve lifestyle and behavior changes to counteract sarcopenia. While exercise has been shown to be an effective treatment for those experiencing sarcopenia, as with other chronic diseases, it makes more sense to aim for prevention rather than treatment particularly as individuals with sarcopenia suffer from reduced strength and muscle mass (5). There is an abundance of scientific literature indicating that nutrition is a critical part of physical activity interventions aimed at preventing loss of muscle with aging (1). In particular, the scientific evidence suggests that dietary protein plays a vital role in building and maintaining muscle mass (1). Optimizing muscle mass is important not only for older Americans, but throughout the lifespan as it is critical in growth, weight management and chronic disease prevention (5). Additionally, as the report discusses, physical activity is important to bone health. Numerous scientific reports indicate that nutrients such as calcium, vitamin D and protein are also extremely important to bone health (2,6). Three servings of low-fat and non-fat dairy a day are recommended in the 2005 Dietary Guidelines to ensure adequate intake of key nutrients for bone health and the prevention of osteoporosis (7).
The PAGAC report makes it clear that the benefits of physical activity extend beyond weight loss. An opportunity for a new message now exists that will help Americans begin to understand that physical activity levels together with diet is what ultimately influences chronic disease risk.
NDC appreciates the opportunity to provide these comments. Please let us know if you have any questions.
Gregory D, Miller, Ph.D., M.A.C.N.
Executive Vice President
Research, Regulatory and Scientific Affairs
DMI/National Dairy Council
- Paddon-Jones, D. Am J Clin Nutr 2008;87(suppl):1562S–6S.
- Heaney, RP. Am J Clin Nutr 2008;87(suppl):1567S–70S.
- Institute of Medicine. Dietary reference intakes: energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academy Press, 2002.
- TJ Doherty, J Appl Physiol. 95:1717-27, 2003.
- Wolfe, RR. Am J Clin Nutr 2006;84:475– 82.
- Weaver, CM. Asia Pac J Clin Nutr. 2008;17 Suppl 1:135-7.
- United States. Dept. of Health and Human Services, United States. Dept. of Agriculture, and United States. Dietary Guidelines Advisory Committee, Dietary Guidelines for Americans, 2005. (6th ed. HHS publication. 2005, Washington, D.C.)
Nutritionist, Nutrition & Fitness Center
College of Health and Rehabilitation Sciences: Sargent College
635 Commonwealth Avenue
Boston, MA 02215
I would like to comment on the Committee's Report on the Physical Activity Guidelines for Americans. I work as a registered dietitian at the Nutrition and Fitness Center at Boston University. I find that numerous students struggle with eating disorders and body image issues which often include excessive exercise, compulsive exercising and/or exercise purging. I am hoping that exercise recommendations for people struggling with these issues will be included in the Physical Activity Guidelines for Americans. Perhaps information on the detrimental effects of excessive exercising will be included.
Molly Kellogg, RD, LCSW
Author of "Counseling Tips for Nutrition Therapists"
As a Registered Dietitian and Psychotherapist who treats eating disorders, I have a suggestion for the final version of the Physical Activity Recomendations. Compulsive/excessive exercise is a serious problem in a subset of those with eating disorders. In addition some exercisers will slip into an eating disorder by increasing their exercise beyond a healthy level. The problem of compulsive exercise is not widely known in the public. You could contribute to public understanding by including a brief mention of the dangers of excessive exercise and it's relationship to eating disorders.
Congratulations on this wonderful report and thank you for considering this input.
Medical Director, Bureau of Chronic Disease Services
Division of Chronic Disease, NYSDOH
Thank you for pulling together a set of physical activity guidelines. I have the same concern, however, as I had with the American Academy of Sports Medicine and the American Heart Association guidelines from 2007. Why do we wait until older adults are at risk for falling to recommend balance training? I understand there may be a lack of evidence of benefit to recommend balance training to all adults, however there should at least be a recommendation for research to be conducted in this area. To make this recommendation only in the cohort of older adults who are already at risk for falling doesn't make a lot of sense to me.
Thank you for the opportunity to offer comments.
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