In the American College of Sports Medicine's annual ranking of the United States' 50 most populous metropolitan areas on the basis of community health, Oklahoma City took last place in 2010, falling five places from its 2009 rank of 45. The ACSM's report, published as part of its American Fitness Index program, cited, among other things, the poor diet of residents, low levels of physical fitness, higher incidences of obesity, diabetes, and cardiovascular disease than the national average, low access to recreational facilities like swimming pools and baseball diamonds, the paucity of parks and low investment by the city in their development, the high percentage of households below the poverty level, and the lack of state-mandated physical education curriculum as contributing factors.