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Arthritis as a Potential Barrier to Physical Activity Among Adults With Heart Disease --- United States, 2005 and 2007

Being physically active is an important component of heart disease (HD) management (1); however patients with HD are less likely to comply with physical activity recommendations than those without HD (2). Arthritis is a common comorbidity among persons with HD, and arthritis-associated joint pain and fear of further joint damage can be an unrecognized barrier to physical activity among persons with HD (CDC, unpublished data, 2008). To provide estimates of the magnitude of this problem at the state level, CDC combined 2005 and 2007 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate overall and age- and sex-specific prevalence of self-reported doctor-diagnosed arthritis among adults aged >18 years with self-reported HD, and the prevalence of physical inactivity among adults with HD by arthritis status. The results indicated that, for these 2 years combined, arthritis affected 57.4% of adults with HD, compared with 27.4% of adults in the general population. Among adults with HD, the likelihood of physical inactivity was 30% greater compared with that of persons with HD but without arthritis, when adjusted for age, sex, race/ethnicity, education level, and body mass index (BMI) (odds ratio [OR] = 1.3). These results suggest that arthritis might be an additional barrier to increased physical activity among persons with HD. Health-care providers and public health agencies should consider addressing this barrier with arthritis-specific or general evidence-based self-management education and exercise programs for their patients with arthritis and HD.

BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. civilian population aged >18 years. Data were collected from the 50 states, District of Columbia (DC), Puerto Rico, and U.S. Virgin Islands. Response rates were calculated using Council of American Survey and Research Organizations (CASRO) guidelines; for 2005 and 2007,* respectively, median response rates were 51.1% and 50.6% and cooperation rates were 75.1% and 72.1%.† A total of 15,725 respondents with missing arthritis or HD data were excluded, resulting in a final sample of 757,959.

HD was defined as a "yes" response to at least one of two questions: "Has a doctor, nurse, or other health professional ever told you that you had… a heart attack, also called a myocardial infarction?" or "…angina or coronary heart disease?" Doctor-diagnosed arthritis was defined as a "yes" response to the question, "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheuma-toid arthritis, gout, lupus, or fibromyalgia?" Physical activity level of respondents was determined from six questions§ that asked about fre-quency and duration of participation in nonoccupational activities (i.e., lifestyle activities) of moderate and vigorous intensity; persons reporting no participation in such activi-ties were classified as inactive. Physical activity guidelines in effect during 2005 and 2007 were used for classifying physical inactivity. Body mass index (BMI) was calculated from self-reported height and weight.

To generate nationwide estimates and 95% confidence intervals (CIs), data from 2005 and 2007 for the 50 states and DC were combined, and an annual average weighting was applied to account for multistage probability sampling. Data for arthritis and heart disease were not collected in all states in 2006, and so, were not included. To assess factors potentially confounding an association between doctor-diagnosed arthritis and physical inactivity among those with heart disease, data were combined across states, in unadjusted and adjusted (by age, sex, race/ethnicity, education level, and BMI) logistic regression models. All other estimates in this report are unadjusted. Estimates were calcu-lated for the 50 states, DC, and territories. Because states are most interested in the number of affected persons and unadjusted prevalence for use in planning and resource allocations, unadjusted state-specific estimates are provided in this report. Statistical significance was determined by the chi-square test (p<0.05).

Average annual adult prevalence was 6.5% for HD and 26.9% for arthritis. Among all respondents, 3.7% reported HD and arthritis, 2.8% reported HD only, 23.2% reported arthritis only, and 70.4% reported neither condition (Table 1). By sex, males had a higher prevalence of HD only and a slightly higher prevalence of both conditions (p<0.01); females had a higher prevalence of arthritis only (p<0.01). The likelihood of having one or both conditions increased with increasing age. Whites were more likely than blacks to have one or both conditions (p<0.01). Prevalence of physical inactivity was lowest among adults without arthritis or HD (11.0%; CI = 10.8%--11.2%), higher among adults with arthritis alone (17.6%; CI = 17.3%--18.0%) and HD alone (21.0%; CI = 20.0%--22.2%), and high-est among adults with both conditions (29.3%; CI = 28.5%--30.2%) (p<0.01) (Figure).

In logistic regression analyses of adults with HD, those with doctor-diagnosed arthritis were 60% more likely to be physically inactive (OR = 1.6; CI = 1.4--1.7; p<0.01); when adjusted for age, sex, race/ethnicity, education level, and BMI, they were 30% more likely to be inactive (OR = 1.3; CI = 1.2--1.4; p<0.01). The state median prevalence estimate for arthritis among adults with HD was 57.4% (range: 46.9% in Hawaii to 68.6% in Mississippi) (Table 2). The state median prevalence of physical inactivity among adults with HD and arthri-tis was 27.2% (range: 20.5% in Colorado to 50.3% in Kentucky); among adults who had HD only, the state median was 19.5% (range: 13.5% in Utah to 38.0% in Kentucky).

Reported by: J Bolen, PhD, L Murphy, PhD, K Greenlund, PhD, CG Helmick, MD, J Hootman, PhD, TJ Brady, PhD, G Langmaid, Div of Adult and Community Health; N Keenan, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

HD and arthritis are common chronic diseases among adults in the United States, affecting 14.1 million and 46.5 million adults in 2006, respectively (3). Each condition is responsible for substantial activity limitation among adults aged >45 years, and persons with both conditions are significantly more limited that those with just one condition (4). The results of this analysis indicate that, during 2005 and 2007, doctor-diagnosed arthritis affected more than half of persons with HD. In this group, the adjusted likelihood of physical inactivity was 30% higher compared with that of persons with HD but without arthritis. State-specific estimates were generally consistent with the overall findings, with differences among states likely attributable to varying distributions of potential confounders (e.g., age, race, and education level). The analyses sug-gest that arthritis might be an additional barrier to being physically active among persons with HD.

The findings in this study are consistent with other research indicating that persons with both arthritis and HD might face additional barriers to increased physical activity (4). This study is the first to quantify the relationship using a population-based sample that provides both national and state-specific estimates of the prevalence and compares physical inactivity for persons with both conditions to those with HD alone.

Both HD and arthritis can interfere with physical functioning, ability to work, and ability to perform household tasks (4). These conditions also might interfere with efforts to become more physically active. Persons with arthritis face the same barriers to being more active as most adults, including lack of motivation and time, competing responsibilities, and difficulty finding an enjoyable activity (5). They also face additional barriers, such as concerns about aggravating arthri-tis pain and causing further joint damage, and they might be unsure about which types and amounts of activ-ity are safe. Qualitative research suggests that persons with arthritis might experience short-term increases in pain when they initiate an exercise program, but that continued participation results in a long-term reduction in symptoms (5).

The findings in this report are subject to at least four limitations. First, arthritis, HD, and physical activity are self-reported and unconfirmed by a health-care provider or objective monitoring; however, such self-reports are considered valid for surveillance purposes (6). Second, BRFSS excludes persons without landline telephones, persons in the military, and those residing in institutions. Estimates are weighted to the population, thus partially correcting for this, but effects might be unpredictable. Third, state prevalence estimates were not adjusted for population characteristics (e.g., age); therefore, comparisons between states should be made with caution. Finally, BRFSS response rates were low; BRFSS weighting procedures partially correct for nonresponse, but the effect of low response rates is uncertain.

Specially tailored self-management education interven-tions, such as the Chronic Disease Self Management Pro-gram and the arthritis-specific Arthritis Foundation (AF) Self-Help Program, help adults learn to manage arthritis pain and discuss how to safely increase physical activity (7). Several exercise programs, including EnhanceFitness, the AF Exercise Pro-gram, and the AF Aquatics Program, are available in many communities and are appropriate for adults with HD and arthritis. Self-directed physical activities, including low-impact activities such as walking, swimming, and biking, also are appropriate for adults with both conditions.**

Greater integration of heart disease and arthritis intervention efforts by health-care providers, payers, and health departments might better address the effects of these co-occurring conditions. Increasing physical activity (e.g., through aerobic exercise and strength training) can benefit persons with arthritis, HD, or both conditions (8,9) by improving physical func-tion and lowering blood pressure and low-density lipoprotein cholesterol levels. Health-care providers should consider whether arthritis-related barriers contribute to physical inactivity in their HD patients and should help those patients learn how to overcome arthritis-specific barriers by providing appropriate advice and referrals. HD patients with arthritis should be encouraged to reduce sedentary behavior; appropriate physical activity might include moderate-intensity aerobics and muscle-strengthening exercises (10).

References

  1. Pearson TA, Blair SN, Daniels SR, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update. Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation 2002;106:388--91.
  2. Zhao G, Ford ES, Li C, Mokdad A. Are United States adults with coronary heart disease meeting physical activity recommendations? Am J Cardiol 2008;101:557--61.
  3. CDC. Summary health statistics for U.S. adults: National Health Interview Survey, 2006. Vital Health Stat 2007;10(235). Available at http://www.cdc.gov/nchs/data/series/sr_10/sr10_235.pdf.
  4. Verbrugge LM, Juarez L. Arthritis disability and heart disease disability. Arthritis Rheum 2008;59:1445--57.
  5. Wilcox S, Der Ananian C, Abbott J, et al. Perceived exercise barriers, enablers, and benefits among exercising and non exercising adults with arthritis: results from a qualitative study. Arthritis Rheum 2006;55:616--27.
  6. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Soz Praventivmed 2001;46(Suppl 1):S3--42.
  7. CDC. Arthritis intervention programs. Available at http://www.cdc.gov/arthritis/intervention/index.htm.
  8. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation 2006;113:2363--72.
  9. US Department of Health and Human Services. 2008 physical activity guidelines for Americans. Hyattsville, MD: US Department of Health and Human Services; 2008. Available at http://www.health.gov/paguidelines.
  10. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007;116:1094--105.

* BRFSS survey data are available at http://www.cdc.gov/brfss/technical_infodata/surveydata.htm.

† The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.

§ Available at http://www.cdc.gov/brfss/questionnaires/pdf-ques/2005brfss.pdf and http://www.cdc.gov/brfss/questionnaires/pdf-ques/2007brfss.pdf.

U.S. Department of Health and Human Services. 1999 Physical activity and health: a report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, CDC; 1996. Available at http://www.cdc.gov/nccdphp/sgr/sgr.htm. New guidelines were released in October of 2008 (2008 Physical Activity Guideline for Americans, available at http://www.health.gov/paguidelines).

** Additional information available at http://www.cdc.gov/arthritis/campaigns/physical_activity/index.htm.

Table 1

TABLE 1. Percentage of respondents aged >18 years who reported heart disease and arthritis, heart disease only, arthritis only, or neither condition, by selected characteristics –- Behavioral Risk Factor Surveillance System, United States, 2005 and 2007 Characteristic Unweighted No. Heart disease and arthritis Heart disease only Arthritis only Neither condition % (95% CI*) % (95% CI) % (95% CI) % (95% CI) Sex Male 286,066 3.9 (3.8–4.0) 3.8 (3.7–3.9) 18.7 (18.4–19.0) 73.6 (73.3–73.9) Female 471,893 3.5 (3.4–3.6) 1.8 (1.7–1.9) 27.4 (27.2–27.6) 67.3 (67.0–67.6) Age group (yrs) 18–44 246,910 0.4 (0.4–0.5) 1.1 (1.0–1.2) 10.6 (10.4–10.8) 87.9 (87.7–88.1) 45–64 303,213 4.2 (4.1–4.3) 3.2 (3.0–3.3) 32.2 (31.9–32.5) 60.4 (60.1–60.8) >65 202,201 12.5 (12.2–12.8) 7.1 (6.9–7.3) 43.7 (43.2–44.1) 36.7 (36.3–37.1) Race/Ethnicity White, non-Hispanic 605,447 4.1 (4.0–4.2) 2.8 (2.7–2.9) 25.6 (25.4–25.8) 67.5 (67.3–67.7) Black, non-Hispanic 56,139 3.4 (3.2–3.6) 2.3 (2.1–2.6) 23.1 (22.4–23.7) 71.3 (70.6–71.9) Hispanic 47,050 1.8 (1.6–2.1) 3.0 (2.6–3.3) 13.0 (12.4–13.6) 82.2 (81.5–82.9) Other, non-Hispanic 42,325 3.3 (3.0–3.6) 2.6 (2.2–2.9) 18.0 (17.3–18.9) 76.1 (75.2–77.0) Education level (yrs) <11 77,412 6.3 (6.0–6.6) 4.2 (3.9–4.5) 23.6 (22.9–24.2) 66.0 (65.3–66.7) 12 232,247 4.4 (4.2–4.5) 3.0 (2.9–3.2) 25.3 (25.0–25.7) 67.3 (66.9–67.7) >13 446,791 2.8 (2.8–2.9) 2.4 (2.3–2.5) 22.0 (21.8–22.3) 72.8 (72.5–73.0) BMI† Underweight/Normal 273,708 2.5 ( 2.4–2.6) 2.3 (2.2–2.4) 18.1 (17.9–18.4) 77.1 (76.8–77.4) Overweight 263,204 3.7 ( 3.6–3.8) 3.1 (3.0–3.3) 23.6 (23.3–23.9) 69.5 (69.2–69.9) Obese 187,106 5.7 ( 5.6–5.9) 3 (2.8–3.1) 30.7 (30.3–31.1) 60.6 (60.1–61.0) Total§ 757,959 3.7 (3.6–3.8) 2.8 (2.7–2.9) 23.2 (23.0–23.4) 70.4 (70.2–70.6) * Confidence interval. † Body mass index, calculated as weight (kg) / height (m)2; normal = 18.5–24.9, overweight = 25.0–29.9, and obese = >30.0. § Number of persons who provided a response for heart disease and for arthritis. Some categories might not add to total because of missing demographic data.
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Table 2

TABLE 2. Prevalence of arthritis among adults aged >18 years with heart disease, and prevalence of physical inactivity* among adults with heart disease, with and without arthritis, by state/area –- Behavioral Risk Factor Surveillance System, United States,† 2005 and 2007 State/Area Physical inactivity among adults with heart disease No. of respondents Arthritis among adults with heart disease Without arthritis With arthritis Weighted no. (in 1,000s)§ % (95% CI¶) % (95% CI) % (95% CI) Alabama 10,447 171 63.9 (59.7–67.8) 18.7 (13.8–24.8) 36.3 (31.6–41.2) Alaska 5,365 12 63.0 (54.5–70.8) 20.2 (11.8–32.3) 23.4 (13.9–36.7) Arizona 9,443 157 51.0 (44.4–57.5) 14.7 (8.6–24.0) 29.1 (22.6–36.5) Arkansas 11,013 96 61.1 (57.7–64.4) 23.9 (19.1–29.5) 26.5 (22.9–30.5) California 11,825 645 48.5 (43.8–53.3) 17.9 (12.9–24.3) 22.2 (16.8–28.8) Colorado 17,887 79 54.6 (50.8–58.3) 17.7 (13.6–22.7) 20.5 (16.9–24.6) Connecticut 12,777 79 53.9 (49.8–58.0) 17.5 (13.4–22.7) 22.9 (18.9–27.4) Delaware 8,183 29 60.8 (56.1–65.3) 19.5 (14.2–26.3) 29.6 (24.4–35.4) District of Columbia 7,700 12 61.5 (55.5–67.2) 16.3 (10.9–23.5) 31.2 (23.5–40.1) Florida 47,739 591 55.5 (52.4–58.5) 24.7 (20.8–29.1) 29.1 (25.8–32.6) Georgia 13,767 221 55.8 (51.7–59.8) 24.2 (18.9–30.4) 33.6 (29.3–38.2) Hawaii 13,019 23 46.9 (42.1–51.7) 15.1 (11.1–20.1) 21.3 (16.3–27.3) Idaho 11,049 38 55.7 (50.5–60.8) 16.6 (12.0–22.6) 24.8 (20.7–29.5) Illinois 10,313 320 57.5 (52.9–61.9) 28.3 (21.9–35.6) 31.2 (26.6–36.2) Indiana 11,626 211 61.9 (57.4–66.2) 17.3 (12.8–22.8) 25.6 (21.8–29.9) Iowa 10,479 83 58.5 (54.5–62.4) 20.1 (15.6–25.4) 27.1 (22.8–31.8) Kansas 17,121 75 56.6 (53.5–59.7) 18.0 (14.9–21.5) 34.6 (31.2–38.2) Kentucky 13,536 151 56.1 (52.6–59.5) 38.0 (32.7–43.7) 50.3 (45.9–54.6) Louisiana 9,620 126 55.4 (50.8–60.0) 36.4 (29.5–43.9) 40.8 (35.3–46.6) Maine 10,790 44 61.4 (57.4–65.3) 20.0 (15.2–25.9) 27.2 (22.8–32.2) Maryland 17,461 138 59.4 (55.4–63.3) 17.6 (13.5–22.7) 26.2 (22.3–30.5) Massachusetts 30,413 164 56.8 (53.6–59.8) 26.1 (21.6–31.1) 29.3 (25.8–33.0) Michigan 19,641 359 65.9 (63.2–68.5) 19.1 (15.5–23.2) 28.3 (25.3–31.6) Minnesota 7,603 105 52.3 (47.5–57.1) 20.5 (15.5–26.6) 20.8 (16.3–26.3) Mississippi 12,257 109 68.6 (65.2–71.9) 31.0 (25.2–37.4) 35.2 (31.2–39.4) Missouri 10,427 201 62.8 (58.6–66.8) 17.2 (12.5–23.1) 24.3 (20.3–28.8) Montana 10,978 23 57.2 (52.9–61.4) 21.6 (15.9–28.6) 22.8 (18.4–27.8) Nebraska 19,276 45 61.2 (57.3–64.9) 24.3 (18.9–30.6) 27.1 (23.1–31.6) Nevada 7,286 60 53.0 (46.7–59.2) 20.0 (12.8–29.8) 23.4 (17.0–31.2) New Hampshire 12,028 37 58.8 (54.8–62.6) 17.1 (13.0–22.1) 24.1 (20.2–28.6) New Jersey 20,899 225 53.5 (49.2–57.7) 22.0 (17.3–27.5) 32.4 (28.3–36.7) New Mexico 12,191 40 52.1 (48.0–56.2) 19.2 (15.0–24.3) 24.5 (20.3–29.3) New York 14,321 477 55.5 (51.4–59.4) 21.2 (16.6–26.7) 26.4 (22.5–30.8) North Carolina 32,038 264 58.9 (56.4–61.3) 22.4 (19.1–26.1) 30.7 (28.1–33.4) North Dakota 8,761 17 56.2 (51.8–60.4) 21.3 (16.1–27.7) 23.6 (18.9–29.0) Ohio 18,727 377 62.2 (58.8–65.5) 17.1 (13.3–21.7) 28.6 (24.7–32.9) Oklahoma 21,170 136 62.6 (59.5–65.5) 21.8 (18.0–26.2) 35.4 (31.8–39.1) Oregon 16,966 84 56.6 (53.0–60.2) 14.8 (11.4–18.9) 22.9 (19.5–26.8) Pennsylvania 26,609 422 63.0 (59.7–66.2) 19.6 (15.4–24.6) 27.5 (24.0–31.3) Rhode Island 8,475 30 60.5 (55.9–64.8) 19.5 (14.2–26.1) 32.6 (27.2–38.4) South Carolina 18,835 131 62.9 (59.9–65.9) 18.4 (14.6–22.9) 28.2 (24.8–31.8) South Dakota 13,786 23 60.3 (56.9–63.5) 20.4 (16.6–25.0) 31.5 (27.9–35.5) Tennessee 9,781 217 61.1 (55.7–66.2) 28.1 (20.9–36.7) 46.7 (41.5–52.0) Texas 23,760 555 51.7 (48.2–55.1) 20.2 (16.1–25.0) 32.2 (28.3–36.3) Utah 10,216 38 54.6 (49.4–59.7) 13.5 (8.2–21.5) 24.8 (19.3–31.3) Vermont 13,699 18 60.3 (56.4–64.0) 15.3 (11.8–19.7) 26.0 (22.1–30.4) Virginia 11,696 198 55.6 (50.7–60.4) 15.5 (11.0–21.3) 27.4 (22.9–32.4) Washington 49,183 144 57.4 (55.2–59.6) 14.9 (12.6–17.6) 21.8 (19.7–24.2) West Virginia 7,998 98 62.0 (58.6–65.3) 30.0 (24.8–35.8) 42.9 (38.7–47.2) Wisconsin 12,335 140 61.0 (56.3–65.6) 16.1 (10.9–23.2) 24.3 (19.9–29.3) Wyoming 11,169 12 57.1 (53.0–61.2) 22.7 (16.8–29.9) 23.7 (19.5–28.5) Median** 57.4 19.5 27.2 Puerto Rico 7,723 131 48.6 (44.6–52.6) 46.9 (40.8–53.0) 56.3 (51.1–61.4) U.S. Virgin Islands 4,960 1 35.3 (27.4–44.1) 15.6 (8.4–27.2) 33.7 (20.9–49.3) * Physical activity level of respondents was determined from six questions that asked about frequency and duration of participation in nonoccupational activities of moderate and vigorous intensity; those reporting no participation in such activities were classified as inactive (engaged in no nonoccupational physical activity); all others were classified as active. † Includes all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. § Weighted annual average number of adults with heart disease who also have arthritis. ¶ Confidence interval. ** Does not include Puerto Rico or the U.S. Virgin Islands.
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Figure

FIGURE. Physical inactivity among adults aged >18 years,* by disease status — Behavioral Risk Factor Surveillance System, United States,† 2005 and 2007
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