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

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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pain and fear of further joint damage can be an unrecognized barrier to physical activity among persons with HD (CDC, unpublished data, 2008).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).

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