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Keywords:

  • Arthritis;
  • Health promotion;
  • Exercise;
  • Physical activity

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Objective

To describe the proportion and characteristics of adults with self-reported, doctor-diagnosed arthritis who report ever having been advised by a health professional to become more physically active and to assess whether the advice was associated with recent physical activity.

Methods

Using population-based data from the 2003 Behavioral Risk Factor Surveillance Survey, respondents were classified according to their arthritis status, whether or not they were ever advised by a health professional to increase their physical activity to help them better manage their arthritis, and whether they engaged in exercise or physical activity within the past month.

Results

Overall, 42% of respondents with arthritis reported ever being advised to increase their physical activity to help their arthritis. Respondents who were more likely to have ever received the advice were female, middle-aged or older, African American, Hispanic, overweight or obese, sedentary or insufficiently physically active, and had higher levels of education. Persons who reported ever receiving the advice were less likely to report that they had exercised within the past month. A higher level of education was the only variable associated with recent exercise or physical activity among those advised to be more active.

Conclusion

Less than 50% of adults with arthritis report ever being advised by a health professional to become more physically active. Advice alone appears insufficient to promote increased physical activity in adults with arthritis.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Arthritis is a common health problem in the United States and the leading cause of disability (1). Exercise and physical activity (PA) can benefit persons with arthritis (2–4). The American College of Rheumatology recommends exercise or PA as part of the treatment of adults with arthritis (5). Apart from arthritis-related benefits, regular exercise or PA decreases morbidity and mortality from cardiovascular disease, cancer, and diabetes (6). However, we reported that <40% of US adults with self-reported, doctor-diagnosed arthritis report meeting the public health recommendation of accumulating at least 30 minutes of moderate-intensity PA on 5 or more days per week or 20 minutes of vigorous-intensity PA on 3 or more days per week (7). To describe the proportion and characteristics of adults with self-reported arthritis who were ever advised by a health professional to become more physically active and to assess whether the advice was associated with recent PA, we analyzed data from a recent, large, population-based survey.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The Center for Disease Control and Prevention's Behavioral Risk Factor Surveillance Survey (BRFSS) annually collects state-based data on preventive health practices and risk behaviors in the noninstitutionalized civilian adult population aged ≥18 years (8, 9). The BRFSS uses a multistage cluster design to ascertain a representative sample of each state's residents; the data from each state are then pooled (9). Information on BRFSS design and sampling methods are reported elsewhere (10). The analyses we report are from 2003 BRFSS data, which contains 266,346 respondents.

Study variables.

Respondents were defined as having doctor-diagnosed arthritis if they answered “yes” to the following question: “Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” A list of diagnoses that constitute arthritis (e.g., rheumatism, polymyalgia rheumatica, osteoarthritis, etc) was provided.

Respondents classified their race and ethnicity as white, African American, Hispanic, or other. Age was defined as the age in years at the time of the interview and classified into 6 categories: 18–24, 25–34, 35–44, 45–54, 55–64, and ≥65 years. Self-reported height and weight were used to calculate body mass index (BMI, kg/m2), which was classified into 3 categories: normal weight (BMI <25 kg/m2), overweight (BMI 25–29.9 kg/m2), or obese (BMI ≥30 kg/m2). Education was classified into 5 categories: ≤8 years, 9–11 years, high school graduate or equivalent, 13–15 years, or >15 years. Smoking status was classified into 2 categories: never/former smoker or current smoker. The PA of respondents was classified into 3 categories: inactive (no moderate- or vigorous-intensity PA), insufficient PA (moderate-intensity PA <5 days per week or <30 minutes per day, or vigorous-intensity PA <3 days per week or <20 minutes per day), or meeting current public health recommendations (≥30 minutes of moderate-intensity PA ≥5 days per week or ≥20 minutes of vigorous-intensity PA ≥3 days per week) (11).

Outcomes.

The 4-question 2003 BRFSS Arthritis Module was administered to participants in 25 states who reported having arthritis. We used the item that asked about exercise and PA (i.e., “Has a doctor or other health professional EVER suggested physical activity or exercise to help your arthritis or joint symptoms?”). Response options were “yes,” “no,” or “don't know/refused.” Exercise and PA within the past month were assessed within the main BRFSS using the question, “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?” Response options were “yes,” “no,” or “don't know/refused.” It is important to note that these questions did not inquire about the intensity of the activity. Because <1% of respondents who completed these questions answered “don't know/refused,” we omitted these cases from the analysis.

Statistical analysis.

We used multivariate logistic regression to characterize associations between study variables and outcomes. Results are reported as odds ratios and 95% confidence intervals, with a 2-sided P < 0.05 considered statistically significant. The analysis was performed with SPSS Software, version 11.5 (SPSS, Chicago, IL).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Nearly one-third (31.8%) of the adults surveyed reported having some form of arthritis. Sixty-eight percent of adults with arthritis were also administered the Arthritis Module containing the question regarding exercise/PA advice. As shown in Table 1, 42.3% of the 56,416 patients analyzed reported receiving advice from a health care provider. Respondents who received the advice were more likely than those who did not receive advice to be women, middle-aged or older, overweight or obese, African American or Hispanic, and have some college education. Inactive respondents were 11% more likely than those meeting PA recommendations to report receiving PA advice, while those who were insufficiently active were 19% more likely than those meeting PA recommendations to receive the advice.

Table 1. Demographics of patients with doctor-diagnosed arthritis, from 2003 Behavioral Risk Factor Surveillance Survey*
CharacteristicUnweighted nReceived advice to increase PA, %OR (95% CI)
  • *

    PA = physical activity; OR = odds ratio; 95% CI = 95% confidence interval; BMI = body mass index.

  • Adjusted for all other covariates.

Total56,41642.3 
Sex   
 Male23,64135.81.00
 Female32,15946.21.59 (1.53–1.65)
Age, years   
 18–241,88032.71.00
 25–344,99635.20.97 (0.86–1.10)
 35–448,72739.01.11 (0.99–1.24)
 45–5412,36143.31.32 (1.18–1.47)
 55–6411,25846.71.50 (1.35–1.68)
 ≥6516,66943.61.47 (1.31–1.63)
Race/ethnicity   
 White47,06641.81.00
 African American3,44848.81.21 (1.12–1.31)
 Hispanic2,71445.01.21 (1.11–1.31)
 Other1,54141.41.08 (0.96–1.20)
BMI, kg/m2   
 Normal18,54236.71.00
 Overweight19,65640.11.22 (1.17–1.27)
 Obese15,47351.11.87 (1.78–1.96)
PA level   
 Meet recommendations9,43941.61.00
 Insufficient20,92345.01.19 (1.13–1.26)
 Inactive22,87440.71.11 (1.05–1.17)
Education, years   
 82,10340.91.00
 9–114,35740.21.00 (0.89–1.13)
 12 or equivalent18,37941.41.07 (0.96–1.19)
 13–1515,47743.11.16 (1.04–1.29)
 >1515,80643.51.26 (1.13–1.41)
Smoking   
 Never/former43,75143.41.00
 Current12,32238.60.96 (0.91–1.00)

Forty-three percent who reported receiving advice had exercised within the past month (Table 2). However, those who ever received the advice were 17% less likely to report exercising within the past month than those who had not received the advice. These results were unchanged when we restricted the analysis to those who theoretically should get this advice (i.e., inactive and insufficiently active adults).

Table 2. Association between receiving advice to become more physically active from a physician or health care professional and exercise within the past 30 days among adults with arthritis
CategoryUnweighted nPersons who have exercised within the past 30 daysOR (95% CI)*
  • *

    Adjusted for sex, age, race and ethnicity, body mass index, education, and smoking status. OR = odds ratio; 95% CI = 95% confidence interval.

Total55,800--
Advised to become active   
 No32,10357.11.00
 Yes23,61342.90.83 (0.79–0.87)

In an analysis restricted to those who reported ever receiving the advice, we found that those with 13–15 years of formal education had nearly 3 times the odds of currently exercising, and those with >15 years of formal education had 4 times the odds of having exercised within the past month. Respondents who reported that they had not engaged in recent exercise or PA were more likely to be women, middle-aged or older, overweight or obese, current smokers, and minority race (Table 3). Again, these results were unchanged when we restricted our analysis to inactive and insufficiently active respondents.

Table 3. Factors associated with reporting PA within previous 30 days in respondents given advice to become more active*
CharacteristicOR (95% CI)
  • *

    PA = physical activity; OR = odds ratio; 95% CI = 95% confidence interval; BMI = body mass index.

  • Adjusted for all other covariates.

Sex 
 Male1.00
 Female0.77 (0.72–0.83)
Age, years 
 18–241.00
 25–341.02 (0.95–1.12)
 35–441.11 (0.97–1.19)
 45–540.41 (0.32–0.52)
 55–640.41 (0.32–0.52)
 ≥650.30 (0.24–0.39)
Race/ethnicity 
 White1.00
 African American0.76 (0.68–0.85)
 Hispanic0.78 (0.68–0.89)
 Other0.77 (0.64–0.92)
BMI (kg/m2) 
 Normal1.00
 Overweight0.84 (0.78–0.92)
 Obese0.51 (0.47–0.55)
Education, years 
 81.00
 9–111.15 (0.96–1.38)
 12 or equivalent1.77 (1.51–2.07)
 13–152.59 (2.20–3.04)
 >154.21 (3.56–4.97)
Smoking 
 Never/former1.00
 Current0.59 (0.54–0.64)

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

These population-based survey data indicate that ∼40% of adults with self-reported arthritis report ever being advised by a health professional that PA might help their arthritis. This is troubling because increased PA has not only been shown to improve arthritis-related symptoms and overall health in persons with arthritis (2–5), but it also reduces medical costs (12).

We found that those most likely to be advised to become more physically active were individuals who were female, middle-aged or older, overweight or obese, and of higher levels of formal education. These results are similar to those obtained by others (13–18). For example, using data from the 2000 National Health Interview Survey, Honda reported that being middle-aged, having a college degree or higher, and being obese were associated with a higher likelihood of receiving physician advice to exercise (13). The reasons that demographic factors associate with receiving advice are unclear. It is possible that health professionals perceive that certain patient subgroups have greater need for or are more receptive to PA advice and target efforts towards these patients. The lower rates of advising men and those with lower education levels, even after adjusting for age, race, activity level, and weight status, are of concern because lower education tends to associate with poorer health outcomes (19).

Among those who report ever being advised, only ∼40% report exercising within the previous 30 days. Interestingly, receiving the advice was associated with lower odds of having recently exercised. Moreover, in analyses restricted to those who reported ever being advised to become more active, increased education was the only variable associated with reporting recent exercise or PA. Unfortunately, many factors associated with receiving the advice (e.g., being a woman, being obese) were negatively associated with recent exercise/PA, suggesting that the advice is not translating into behavior among the subgroups who might benefit most.

Although the cross-sectional nature of the BRFSS prohibits certainty about whether the advice preceded the recent exercise or PA, these findings suggest that merely advising increased PA is insufficient to promote a more active lifestyle. Glasgow et al reported that among patients who received exercise counseling from their physicians, only 40% reported receiving assistance in planning an exercise routine or followup support (14). As shown with smoking cessation (20), merely providing advice, in the absence of a discussion that is tailored to the needs of the individual, simply is not enough to help most patients adopt health behaviors. This may be especially so with arthritis patients who may have been previously (inappropriately) advised to limit their PA to protect their joints, and who have little knowledge about how to initiate exercise or PA in a safe and gradual manner. Iversen and colleagues reported that only about one-quarter of exercise-related discussions between rheumatologists and their patients culminated with an exercise prescription (21). This implies that, even within the context of a PA discussion for arthritis, health professionals may not provide enough specific information to help their patients become more active.

Our findings are subject to limitations. Apart from the previously mentioned cross-sectional nature of the BRFSS, all variables relied on self reports, including the diagnosis of arthritis. Moreover, we were unable to distinguish among the different types of arthritis/rheumatic diseases. Thus, these findings may not generalize to patients with specific arthritic or rheumatic diseases. The BRFSS also does not include persons without telephone service or those in the military or in institutions.

In conclusion, our results indicate that most adults with arthritis are not being advised to become more active. However, our results also suggest that those who receive the advice are less likely to be active than those who do not receive the advice, implying that advice alone is insufficient to promote PA. Given the efficacy of highly targeted PA interventions (21), systematic efforts should be made to ensure that not only are persons with arthritis advised to become more physically active, but that they are also given the education, resources, and support to do so.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  • 1
    Centers for Disease Control and Prevention (CDC). Prevalence of doctor-diagnosed arthritis and possible arthritis: 30 states, 2002. MMWR Morb Mortal Wkly Rep 2004; 53: 3836.
  • 2
    American College of Rheumatology Subcomittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum 2000; 43: 190515.
  • 3
    Van den Ende CH, Vliet Vlieland TP, Munneke M, Hazes JM. Dynamic exercise therapy for rheumatoid arthritis: Cochrane review. In: The Cochrane library. 4th ed. Oxford: Update Software; 2001.
  • 4
    US Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta (GA): US Department of Health and Human Services; 1996.
  • 5
    Chang R, Roubenoff R, Mayer J, Brandt KD, Schanberg LE. Work group recommendations: 2002 exercise and physical activity conference, St. Louis, Missouri. Session IV. Exercise in the presence of rheumatic disease. Arthritis Rheum 2003; 49: 280.
  • 6
    US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic disease Prevention and Health Promotion, Division of Nutrition and Physical Activity. Promoting physical activity: a guide for community action. Champaign (IL): Human Kinetics; 1998.
  • 7
    Fontaine KR, Heo M, Bathon J. Are US adults with arthritis meeting public health recommendations for physical activity? Arthritis Rheum 2004; 50: 6248.
  • 8
    Centers for Disease Control and Prevention. Health risks in America: gaining insight from the Behavioral Risk Factor Surveillance Survey System. Atlanta (GA): US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 1997.
  • 9
    Centers for Disease Control and Prevention. 2001 Behavioral Risk Factor Surveillance Survey: users manual. Atlanta (GA): US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 2002.
  • 10
    Gentry EM, Kalsbeek WD, Hogelin GC, Jones JT, Gaines KL, Forman MR, et al. The behavioral risk factor surveys. II Design, methods, and estimates from combined state data. Am J Prev Med 1985; 1: 914.
  • 11
    Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995; 273: 4027.
  • 12
    Wang G, Helmick CG, Macera C, Zhang P, Pratt M. Inactivity-associated medical costs among US adults with arthritis. Arthritis Rheum 2001; 45: 43945.
  • 13
    Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot 2004; 18: 3707.
  • 14
    Glasgow RE, Eakin EG, Fisher EB, Bacak SJ, Brownson RC. Physician advice and support for physical activity: results from a national survey. Am J Prev Med 2001; 21: 18996.
  • 15
    Ashenden R, Silagy C, Weller D. A systematic review of the effectiveness of promoting lifestyle change in general practice. Fam Pract 1997; 14: 16076.
  • 16
    Podl TR, Goodwin MA, Kikano GE, Stange KC. Direct observation of exercise counseling in community family practice. Am J Prev Med 1999; 17: 20710.
  • 17
    Simons-Morton DG, Calfas KJ, Oldenburg B, Burton NW. Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. Am J Prev Med 1998; 15: 41330.
  • 18
    Eaton CB, Menard LM. A systematic review of physical activity promotion in primary care office settings. Br J Sports Med 1998; 32: 116.
  • 19
    Ross CE, Wu C. The links between education and health. Am Socio Rev 1995; 60: 71945.
  • 20
    Zapka J, Goins KV, Pbert L, Ockene JK. Translating efficacy research to effectiveness studies in practice: lessons from research to promote smoking cessation in community health centers. Health Promot Pract 2004; 5: 24555.
  • 21
    Iversen MD, Eaton HM, Daltroy LH. How rheumatologists and patients with rheumatoid arthritis discuss exercise and the influence of discussions on exercise prescriptions. Arthritis Rheum 2004; 51: 6372.