Could arthritis be a barrier to weight loss and physical activity ..

Could Arthritis Be a Barrier to Physical Activity Among Persons with Diabetes and Other Chronic Conditions? J. Bolen, C. Helmick, J. Hootman, T. Brady, L. Ramsey. CDC Arthritis Program Format for today‘s call • Prevalence of arthritis among people with diabetes, heart disease, obesity, inactivity. • Characteristics of people with arthritis who are and are not physically active • Arthritis as a barrier to increased physical activity – Characteristic of successful exercisers with arthritis – Arthritis-specific interventions • Examples of successful collaborations between state arthritis programs and other chronic disease programs 2 Take home message Anyone seeking to increase physical activity in the population of adults with other chronic diseases or risk factors (e.g. diabetes cardiovascular disease, obesity and physical activity) has to address arthritis. - A large proportion of people with chronic diseases also have arthritis. - Arthritis presents unique barriers to increased physical activity. 3 Prevalence of arthritis among adults with diabetes, heart disease, obesity and physical inactivity Julie Bolen, PhD, MPH jcr2@cdc.gov 4 Almost Half of Adults with Diabetes also Have Arthritis (NHIS, 2003-2005) Arthritis (46.4 million) Diabetes (17.2 million) 7.8 million people with both 5 Over Half of Adults with Heart Disease also Have Arthritis (NHIS, 2003-2005) Arthritis Heart Disease (13.3 million) 6.9 million people with both (46.4 million) 6 Arthritis among adults with diabetes, heart disease, obesity, inactivity: 2003-05 BRFSS State Medians. 70 60 50 40 30 20 10 0 Arth Diabetes Heart Dis Obesity Inactive 7 18+ Men Women Increased physical activity (conditioning and strengthening) helps several chronic conditions – For people with arthritis, can reduce joint pain, improve function, and improve mental health – For people with diabetes, can reduce blood glucose and risk factors for complications – For people with heart disease, can improve cardio-vascular functioning and help control weight 8 Addressing arthritis is critical • There are barriers to increasing physical activity faced by most adults, e.g. lack of time, motivation, competing responsibilities, etc • Also arthritis-specific barriers, e. g. pain, fear of increased pain and possible joint damage, don‘t know which activities are ―safe‖ 9 State-specific data for diabetes • Below are examples from the 2003-2005 BRFSS demonstrating the high prevalence of arthritis among adults with diabetes • State medians and ranges are presented 10 Definitions Case Definitions Diabetes, Arthritis, and Obesity • Have you ever been told by a doctor that you have diabetes? • 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? • Body Mass Index > 30 is obese - About how tall are you without shoes? - About how much do you weigh without shoes? 11 Definitions Physical Activity • Physical activity is estimated from a combination of 6 questions that puts people into one of 3 categories. • We focus on those who are Inactive (no reported moderate or vigorous activity) • Moving people from the inactive group to a higher level of activity provides most benefit 12 Prevalence of Arthritis Among Adults with Diabetes Median 52.6% (Range 36.2% HI – 59.3% MO) 36.2 – 48.8 49.3 – 55.0 55.2 – 59.3 13 Arthritis Among People with Diabetes by Age, Sex, and Race (state medians) 70 60 66 53 44 35 28 20 10 0 18-44 45-64 65+ 50 Percent 40 30 56 55 53 M F White Black Hispanic Age Sex Race 14 Arthritis Prevalence Among Adults in the General Population and Adults with Diabetes by Age Group Age Group Median all Median and Range adults People with diabetes 18-44 45-64 65+ 11% 36% 56% 28% (13% CO – 42% VA) 53% (33% HI – 61% MS) 63% (45% HI – 71% MS) 15 Prevalence of Arthritis among Adults with Diabetes who are Inactive Median 61.1% (Range 43.9% CA – 73% IA) 43.9 – 56.9 57.0 – 63.9 64.0 – 73.0 16 Prevalence Data Summary Diabetes and Arthritis • Overall, arthritis affects over half of the adults with diabetes. (Also true for heart disease) Arthritis is especially prevalent among women and adults 45 years and older with diabetes. (Also true for heart disease) Arthritis prevalence among people with diabetes who are inactive is about 61%, with state estimates ranging from 44% to 73%. 17 • • Characteristics of people with arthritis who are and are not physically active Jennifer Hootman, PhD, MPH tzh7@cdc.gov 18 Healthy People 2010 PA Objectives 22-1 Reduce % inactive (no LTPA) 22-2 Increase % engaging in moderate PA (5x30) 22-3 Increase % engaging in vigorous PA (3x20) 22-4 Increase % performing strengthening exercises People with arthritis are a specific target group for these objectives. 19 • Expert Panel – 2002 St. Louis Conference International Conference on Health Promotion and Disability Prevention for Individuals and Populations with Rheumatic Disease: Evidence for Exercise and Physical Activity Arthritis-specific PA recommendation • Evidence for at least 3x30 moderate PA recommendation for adults with arthritis • • • • ―Lowers the bar‖ for frequency per week Emphasizes moderate intensity ―Joint Friendly‖ - low impact Can do in 10-15 min increments 20 Reference: Arthritis and Rheumatism 2003;49(3): 453-454. Theoretical Rationale Risk of "Poor Outcome" 2.5 Very High Activity 2 Immobile/inactive 1.5 1 0.5 0 Low to moderate activity High Activity Optimal Range 21 CDC Arthritis Program Focus • CDC emphasizes just getting out of the inactive category • Gives ―biggest bang for the buck‖ • Easier to identify target group (e.g. ―inactives‖) • Refer to arthritis-specific community-based exercise programs 22 Meeting PA Recommendations* US Adults With and Without Arthritis 50 40 Percent (%) 2002 National Health Interview Survey 43.6 36.4 25.8 16.3 33.4 32.3 39.5 Arthritis No Arthritis 30 20 10 0 Inactive 21.5 Meet Gen Rec Meet Arth Rec Streng Ex * HP2010 Goal Source: Shih M, et al. Am J Prev Med, 2006;30(5):385-93. 23 Factors associated with inactivity among adults with arthritis More inactive: • • • • • • • • • • Females Older age (45+ yrs) Race/Ethnicity (NHB, Hisp) Education (HS or less) Frequent Anxiety/Depression Functional limitations Social limitations Special equipment Severe joint pain No HCP counseling for ex Less inactive: • Perceived access to fitness program/facility No association: • Body mass index • Presence and number of comorbid conditions • Location of joint pain Source: Shih M, et al. Am J Prev Med, 2006;30(5):385-93. 24 Arthritis as a barrier to increased physical activity Characteristic of successful exercisers with arthritis Arthritis-specific interventions Examples of successful collaborations between state arthritis programs and other chronic disease programs Teresa Brady, PhD tob9@cdc.gov 25 Common Barriers Groups • • • • • • • Fatigue Lack time No ex. buddy Should/don‘t Not a priority Other priorities Don‘t enjoy Exer. 100% 83% 50% 50% 67% 33% 50% Non-Ex 100% 50% 83% 67% 33% 67% 50% 26 Barriers to Physical Activity Among People with Arthritis • Purpose – Identify barriers to PA among PWA – Compare regular exercises/non-exercisers • 12 focus groups, segmented by – Exercise status (30 min--3 days/no more than 20 min--2 days – Race (Caucasian/African American) – SES (HS Ed or less/more than HS) 27 Arthritis Specific Barriers Groups Exer Non-exer • Pain 100% 100% 83% 100% • Perceived neg. outcomes 83% 100% • No Arthritis specific pgm • Weather 83% 67% • Dr. not mention 50% 50% 28 Additional Arthritis Specific Barriers among Non Exercisers Groups • • • • ―I can‘t‖ Lack pos. outcomes Fear Dr. not refer Exer. Non-Ex 17% 0% 0% 0% 67% 67% 50% 50% 29 Conclusions • PWA face both general and arthritis specific barriers to PA • Among PWA Exercisers and Nonexercisers face many of the same barriers • Exercisers less likely to allow barriers to prevent exercise – Exercisers modified their exercise – Non-Exercisers gave up exercise 30 Implications To increase physical activity among PWA : • Address fear and other psychological barriers • Provide arthritis specific instruction and referral to programs • Increase arthritis specific facilities/programs • Incorporate problem-solving skills 31 Addressing Barriers to Physical Activity among People with Arthritis Use evidence-based interventions to: • Instruct on appropriate physical activity • Address fears • Provide arthritis-safe exercise • Teach problem solving skills 32 Evidence-Based Interventions • Self Management Education Programs • Physical Activity/Exercise Programs • Health Communications 33 • Self Management Education Programs Evidence-Based Interventions: – Chronic Disease Self Management Program – Arthritis Self Management Program (Arthritis Foundation Self-Help Program; aka ASHC) 34 Self Management Education Chronic Disease Self Management Program (CDSMP): • • • • Small group classes Lead by trained lay leaders 6 weeks; 2 ½ hours week Designed to teach generalizable skills and enhance self efficacy – Goal setting, action planning – Problem-solving, communication with providers • Addresses multiple chronic conditions • Developed, evaluated by Stanford University 35 Self Management Education Chronic Disease Self Management Program (CDSMP) Improved Outcomes: Self efficacy Self rated health Disability Role activity Energy/fatigue Health distress 6 mo. √ √ √ √ √ √ 2 yrs. √ √ √ √ MD/ER visits Hospitalization √ √ √ 36 Lorig et al 1999, 2001 Arthritis Self Management Program/ Arthritis Foundation Self Help Program • Small group education • Covers problem-solving, exercise, relaxation, communication, etc. • 6 week series of 2-2.5 hours/week • Taught by trained volunteers • Designed to increase self efficacy • Developed by Stanford University • Disseminated by AF since 1981 37 Evidence-Based Interventions • Self Management Education Programs – CDSMP/ASMP • Physical Activity/Exercise Programs • Health Communications 38 Evidence-Based Interventions: • Physical Activity/Exercise Programs – EnhanceFitness – Arthritis Foundation Exercise program (aka PACE) – Arthritis Foundation Aquatics Program 39 Physical Activity Interventions EnhanceFitness: • Multi-component group exercise program – Flexibility, Strengthening, Conditioning, Balance components mandatory • Led by certified fitness instructors • Generic; not arthritis specific • Safe for physically unfit seniors including ‗near frail‘ • Developed and evaluated at Univ. of WA • Disseminated by Project Enhance 40 Physical Activity Interventions EnhanceFitness—Initial Study Results (RCT) • 85% completion rate • Significant improvements in: – – – – – – Depression General health perception Mental health Lack of role limitations Social function Energy/fatigue • Trend toward significance in – Pain – Physical function » Wallace et al J Gerontology 1998 41 • Community recreational exercise program • Endurance and relaxation activities, health education • Basic and advanced levels • 1-1.5 hrs, 1-3 times per week, 8 wks • Activities seated, standing or lying • Health/fitness professionals instructors • Developed by AF in 1987, revised in 1999 42 Arthritis Foundation Exercise Program Arthritis Foundation Aquatic Program • Moderate intensity aquatics group program; video available • Covers ROM, strength and endurance • Basic and advanced levels • 1-hr session,1-3 times per wk, 6-10 wks • Taught by trained fitness/health leaders • Co-developed with YMCA in 1983, revised as needed every 3 years 43 AF Physical Activity/ Exercise Programs: Aquatics PACE Knowledge Exercise Fx Relaxation Fx Self Care Behav. Self Efficacy Pain Depression Helplessness Disability/Function Jt. Efforts Educize             Brady, Kreuger, et al 2003 44 Evidence-Based Interventions: • Self Management Education Programs • Physical Activity/Exercise Programs – EnhanceFitness – Arthritis Foundation Exercise program (aka PACE) – Arthritis Foundation Aquatics Program • Health Communications – Physical Activity. The Arthritis Pain Reliever – Buenos Diaz, Artritis 45 Health Communications The use of communication strategies to inform and influence individual and community decisions that enhance health. To be effective: Messages and materials need to resonate with the target audience 46 English Health Communications Campaign • Directed toward Caucasian and African American adults with arthritis – Ages 45-70, lower SES • Released in 2003 • Used by 35 state health departments, at least 10 Arthritis Foundation Chapters • Address key motivators – Pain relief; ability to do more 47 Key Public Health Message • 30 minutes of moderate activity • At least 3 days per week* – ACR consensus recommendations – Arth Rheum 2003;49: 453-454 • Can be done in 10 minute increments (makes it do-able) 48 Campaign Materials: • Radio Spot • Recorded • Script for local live announcer • Brochure and Brochure Holder for pharmacies, MD offices churches, etc • Print PSAs • Posters 49 Themeline: Physical Activity. The Arthritis Pain Reliever. 50 Campaign Materials 51 Physical Activity. The Arthritis Pain Reliever. Pilot Test Results N = 1200, from 4 sites • 50% have read/heard something about relieving arthritis pain with PA in past mo. • 20% increased PA in last month in response to something heard/read • 92% agree that moderate PA can be helpful even if done 10 min./time 52 Physical Activity. The Arthritis Pain Reliever. Controlled Trial Results 6 month follow up, N = 300 (E1, E2, C) • Campaign recognition significantly greater in E1 • Significant baseline-follow up changes in E1 – Knowledge • Moderate PA can reduce arthritis pain • Moderate PA helpful 10 min./time • Possible to relieve arthritis pain without meds – Behavior: participation in moderate PA 53 Hispanic Campaign • Designed to promote physical activity among Spanish-speaking people with arthritis • Target audience similar to English campaign • Objectives similar to English campaign • Materials similar to English campaign – + outdoor advertising • Concepts and executions different 54 55 Buenos Dias, Artritis Pilot Test Summary Results Telephone survey: N = 817 (CA, FL, OK, WI) • 2/3rd Read/heard something about exercise to beat arthritis • 27% Increased exercise in response to something heard/read in past month • 29% likely to increase exercise in next month • 88% agree exercise helpful even 10 minutes/time • 3 states modest increase to AF Spanish info line after campaign 56 • Self Management Education Programs – Chronic Disease Self Management Program – Arthritis Self Management Program (Arthritis Foundation Self-Help Program; aka ASHC) Evidence-Based Interventions: • Physical Activity/Exercise Programs – EnhanceFitness – Arthritis Foundation Exercise program (PACE) – Arthritis Foundation Aquatics Program • Health Communications – Physical Activity. The Arthritis Pain Reliever – Buenos Diaz, Artritis 57 Missouri Arthritis Program Collaboration with Missouri Diabetes Program — Regional Arthritis Center 58 Other examples of state program collaboration • Kentucky Arthritis Program and Physical Activity and Nutrition Program are working together to expand the reach of multiple evidence based interventions through their local health department structure. • Michigan ―Partners on the Path‖ -Arthritis Program is involved in a statewide initiative to expand the reach of Chronic Disease Self Management Program (CDSMP) through Area Agencies on Aging (AAAs) and the Diabetes Outreach Network (DON). 59 Public Health Implications • Diabetes and other chronic disease programs could improve success in promoting physical activity by addressing arthritis as a potential barrier • Arthritis, diabetes, cardiovascular health, and obesity programs are targeting many of the same people with a similar message: increase physical activity • Evidence-based programs can help people with arthritis and other chronic conditions become more physically active. 60 Future Plans Evaluation of general physical activity communitybased program – ―Active Living Every Day‖ – Additional evaluation of ―Enhance Fitness‖ • Evaluation of arthritis-specific walking program – ―Arthritis Foundation Walk with Ease‖ • Develop new, more challenging land-based and group exercise programs for people with arthritis – Fitness and exercise for people with arthritis. 61 Questions? 62