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Keywords:

  • health care surveys;
  • disability evaluation;
  • health services needs and demand;
  • gait

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Objective: The purpose of this study was to evaluate the extent to which level of obesity was associated with hours of personal care among people with mobility impairments.

Research Methods and Procedures: The analytic sample consisted of 9496 respondents to the Adult Disability Follow-Back Survey (NHIS-D Phase II) who had mobility difficulty and difficulty with at least one activity of daily living or instrumental activity of daily living. Logistic regression analyses determined the relationship between level of obesity and receipt of any paid or unpaid help, controlling for potential confounders. In addition, differences in hours of help by level of obesity were evaluated using multiple regression.

Results: In the crude analysis, obese respondents were significantly less likely to receive any paid help than normal weight respondents (average odds ratio 0.75) and received significantly fewer hours of both paid and unpaid help. The difference in prevalence of receipt of any unpaid and any paid help by level of obesity was explained by adjustment for age and other demographic characteristics. Adjusted hours of paid and unpaid help were equivalent for those with and without obesity.

Discussion: Obese people with mobility impairments received less help with personal care than those of normal weight, although these findings are explained by demographics. Nevertheless, these findings raise public health concerns given the growing obesity epidemic in the United States and lack of available resources to support younger persons with disabilities.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

The prevalence of disability for those 30 to 49 years old in the U.S. is rising, due largely to obesity and its associated disorders (1). People with disability often require personal assistance to perform basic activities of daily living (ADL).1 In general, disabled persons with higher levels of impairment need and use more hours of personal care (2). Although it is not known whether the presence of obesity impacts the receipt of personal care assistance in people with disabilities, the slower speed of activities observed in obese people may require more time for personal help. In addition, severely disabled obese typically require the assistance of two or more people to perform most ADL safely (3).

To our knowledge, the relation between obesity and receipt of personal care has not been previously described. We hypothesized that disabled people with obesity would be more likely to receive any personal care than disabled people of normal weight and would also require and receive more hours of care for personal assistance.

Research Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Data Source and Sample

We used data from Phase II of the 1994 to 1995 National Health Interview Survey Disability supplement. In 1994 and 1995, all National Health Interview Survey (NHIS) respondents completed the NHIS-D, Phase I, supplemental questionnaire on disability, which was used to screen for eligibility for NHIS-D, Phase II, the Adult Disability Follow-Back Survey (DFS). Taking into account response rates for NHIS-D, Phase I, and DFS, overall response rate for 2 years of the survey was 85%, resulting in a sample size of 25, 805 adults 18 and older with a variety of health conditions and disabilities.

We identified 12, 814 DFS respondents who reported difficulty walking a quarter of a mile, climbing up 10 steps, or standing for >2 hours. We included 10, 017 respondents who also reported having at least one ADL or instrumental ADL difficulty and excluded 521 respondents who had a BMI < 18.5 kg/m2 because underweight is associated with serious illness, which could potentially confound the study results (4). The final sample size was 9496.

Measures

We used three dichotomous variables to define receipt of personal care: receipt of any help, receipt of any formal (paid) help, and receipt of any informal (unpaid) help. We created interval variables representing total hours of formal care received per week and, separately, total hours of informal care received per week. We used a non-parametric imputation method (5) to reclaim a total of 1198 cases in our sample that were missing number of hours of help per day provided by each helper.

We classified respondents as: normal weight (BMI 18.5 to 24.9, referent group), overweight (25 < BMI ≤ 29.9), mildly obese (30 < BMI ≤ 34.9), moderately obese (35 < BMI ≤ 39.9), and morbidly obese (BMI > 40 kg/m2). We considered a number of factors associated with receipt of care and obesity as potential confounders, including: age, race/ethnicity, education, insurance status, living arrangement, and use of an assistive device. Two measures were used to control for the physical severity of the respondent's condition: a count of ADL difficulties (0 to 7) and a count of instrumental ADL difficulties (0 to 8).

Analytic Approach

We performed all analyses using sampling weights in STATA to account for core NHIS sampling design and non-response rate. Logistic regression analyses provided estimates of odds ratios (ORs) to examine the relationship between obesity and likelihood of receipt of any paid or unpaid help. Differences in log-transformed hours of help (logarithmic transformation of variable due to skewness) by level of obesity were evaluated using multiple regression.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

Table 1 shows the characteristics of people with mobility impairments by level of obesity. Although the prevalence of receipt of unpaid help did not vary substantially by level of obesity, the prevalence of receipt of paid help was lower for all categories of overweight/obesity (Table 2). Hours of paid and unpaid help received in a week were lower for those with any class of obesity as compared with those of normal weight (p < 0.001) (Table 2).

Table 1. . Characteristics of people with mobility impairments by level of obesity
 Normal weight (n = 3299)Overweight (n = 3092)Mild obesity (n = 1714)Moderate obesity (n = 747)Morbid obesity (n = 644)
  • *

    p < 0.05, statistically significant differences between groups.

  • p < 0.01, statistically significant differences between groups.

  • p < 0.001, statistically significant differences between groups.

%
Age (years)*
 18 to 441916182025
 45 to 642533384346
 65 to 741923242418
 75+3727191311
Female6257656982
Race/ethnicity*
 White8074716565
 Non-black Hispanic71011109
 Black1216182526
Education*
 Less than high school4144474743
 High school3433333335
 Some college1513131214
 College109788
Lives alone*3430292829
Health insurance
 Uninsured57769
 Private insurance1618202121
 Medicare and private4138332620
 Medicare and Medicaid1212131717
 Medicare only1513131311
 Medicaid only910111319
 Other public insurance22333
Poverty status*
 Above or at poverty6969675955
 Below poverty1919222828
 Unknown poverty1212111215
Any ADL difficulty7981848487
Table 2. . Prevalence of help and average hours of help by level of obesity among people with mobility impairments
 Normal weight (n = 3299)Overweight (n = 3092)Mild obesity (n = 1714)Moderate obesity (n = 747)Morbid obesity (n = 644)
  • *

    p < 0.05, statistically significant differences between groups.

  • p < 0.01, statistically significant differences between groups.

  • p < 0.001, statistically significant differences between groups.

Any help (%)6360626264
Any paid help (%)1311101011
Any unpaid help (%)5755575759
Hours of total help [mean (SD)]26.5 (51.2)21.8 (44.3)20.8 (43.8)21 (43.8)23.4 (44.0)
Hours of paid help [mean (SD)]2.9 (16.2)2.0 (11.9)1.3 (8.9)1.6 (9.7)2.5 (15.2)
Hours of unpaid help [mean (SD)]23.5 (48.1)19.8 (42.6)19.5 (43.0)19.4 (41.7)20.7 (39.9)

Logistic regression models showed that people in all categories of obesity were less likely to receive any paid help than those classified as normal weight (mild obesity OR, 0.77; 95% confidence interval (CI), 0.63 to 0.94; moderate obesity OR, 0.64; 95% CI, 0.48 to 0.84; morbid obesity OR, 0.83; 95% CI, 0.62 to 1.1); however, this was no longer observed after adding age to the model and was not evident after further adjustment for other potential confounders. There was no crude or adjusted relationship between class of obesity and the likelihood of receiving any unpaid help.

The relationship between obesity and hours of paid help was not significant after adjusting for age in the multiple regression model. The relationship between obesity and hours of unpaid help was explained after adjusting for age, gender, race, living arrangement, insurance coverage, and poverty status.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

We found that the prevalence of receipt of any paid help was lower across levels of obesity, and the total hours of help received in a week were lower (in both paid and unpaid help) than those received by mobility-impaired persons of normal weight. Differences in these crude estimates were explained by differences in the distributions of confounding variables such as age, gender, race, living arrangement, insurance coverage, and poverty status.

Regardless of obesity level, inadequate support for personal assistance is a concern for younger and middle-aged adults with disability because unmet needs for personal assistance place people at increased risk for adverse health consequences such as falls, injuries due to falls, bedsores, and contractures (6, 7). Traditionally, the bulk of personal assistance with ADLs comes from informal support networks of families and friends. Disabled persons who are younger or middle-aged may not have the same types of informal networks available to the elderly, and their access to formal services may be limited. Insurance rarely covers personal assistance services for chronic conditions, and most formal support that exists is available primarily to the elderly or children and adults with longstanding special health care needs.

In conclusion, we found that the likelihood of receipt of paid and/or unpaid care and hours of paid and/or unpaid care received by obese respondents were comparable with other mobility-impaired adults after accounting for differences in age and other sociodemographics. Concurrent obesity and disability may place individuals at increased risk for adverse health consequences due to lack of available resources to support younger persons with disabilities. Personal caregivers may also be at increased risk for injury and illness. Future work in this area should assess the level of caregiver effort, safety, and perceived burden of care. Our study design, limited by survey questions, did not allow us to assess these areas.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References

We thank Jason Roy for assistance with imputation of missing data. Funding for this manuscript was supported, in part, by a National Service Research Award (Federal Grant T32 HS00011) funded by the Agency for Health Care Research and Quality.

Footnotes
  • 1

    Nonstandard abbreviations: ADL, activities of daily living; NHIS, National Health Interview Survey; DFS, Adult Disability Follow-Back Survey; OR, odds ratio; CI, confidence interval.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research Methods and Procedures
  5. Results
  6. Discussion
  7. Acknowledgement
  8. References
  • 1
    Lakdawalla, D., Bhattacharya, J., Goldman, D. (2004) Are the Young Becoming More Disabled? Health Track 23: 168176.
  • 2
    Allen, S. M., Foster, A., Berg, K. (2001) Receiving help at home: the interplay of human and technological assistance. J Gerontol B Psychol Sci Soc Sci. 56: S374S382.
  • 3
    Rotkoff, N. (1999) Care of the morbidly obese patient in a long-term care facility. Geriatr Nurs. 20: 309313.
  • 4
    Huang, J., Marin, E., Yu, H., et al (2003) Prevalence of overweight, obesity, and associated diseases among outpatients in a public hospital. South Med J. 96: 558562.
  • 5
    Allen, S., Resnik, L.. Promoting independence for wheelchair users who live alone: the role of home accommodations. Gerontologist. (in press).
  • 6
    Desai, M. M., Lentzner, H. R., Weeks, JD. (2001) Unmet need for personal assistance with activities of daily living among older adults. Gerontologist 41: 8288.
  • 7
    LaPlante, M. P., Kaye, H. S., Kang, T., Harrington, C. (2004) Unmet need for personal assistance services: estimating the shortfall in hours of help and adverse consequences. J Gerontol B Psychol Sci Soc Sci. 59: S98S108.