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Could arthritis be a barrier to weight loss and physical activity among persons with diabetes

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Could Arthritis Be a Barrier to Physical Activity Among Persons with Diabetes ... Arth Rheum 2003;49: 453-454. Can be done in 10 minute increments (makes it do-able) ... – PowerPoint PPT presentation

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Title: Could arthritis be a barrier to weight loss and physical activity among persons with diabetes


1
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
2
Format for todays 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

3
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.

4
Prevalence of arthritis among adults with
diabetes, heart disease, obesity and physical
inactivity Julie Bolen, PhD, MPH jcr2_at_cdc.gov
5
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
6
Over Half of Adults with Heart Disease also Have
Arthritis (NHIS, 2003-2005)
Heart Disease
Arthritis
(46.4 million)
(13.3 million)
6.9 million people with both
7
Arthritis among adults with diabetes, heart
disease, obesity, inactivity 2003-05 BRFSS
State Medians.
8
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

9
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,
    dont know which activities are safe

10
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

11
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 gt 30 is obese
  • - About how tall are you without shoes?
  • - About how much do you weigh without
    shoes?

12
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

13
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
14
Arthritis Among People with Diabetes by Age, Sex,
and Race (state medians)
70
66
60
56
55
53
53
50
44
40
Percent
35
30
28
20
10
0
18-44
45-64
65
M
F
White
Black
Hispanic
Age
Sex
Race
15
Arthritis Prevalence Among Adults in the General
Population and Adults with Diabetes by Age Group
16
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
17
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.

18
Characteristics of people with arthritis who are
and are not physically active Jennifer Hootman,
PhD, MPH tzh7_at_cdc.gov
19
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.
20
Arthritis-specific PA recommendation
  • 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
  • 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

Reference Arthritis and Rheumatism 200349(3)
453-454.
21
Theoretical Rationale
Very High Activity
Immobile/inactive
High Activity
Low to moderate activity
Optimal Range
22
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

23
Meeting PA Recommendations US Adults With and
Without Arthritis
2002 National Health Interview Survey
Source Shih M, et al. Am J Prev Med,
200630(5)385-93.
24
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 co-morbid conditions
  • Location of joint pain

Source Shih M, et al. Am J Prev Med,
200630(5)385-93.
25
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_at_cdc.gov
26
Common Barriers
Groups
  • Fatigue
  • Lack time
  • No ex. buddy
  • Should/dont
  • Not a priority
  • Other priorities
  • Dont enjoy

Exer. Non-Ex 100 100 83 50 50
83 50 67 67 33 33 67 50 50
27
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)

28
Arthritis Specific Barriers
  • Exer Non-exer
  • 100 100 83 100
  • 83 100
  • 83 67
  • 50 50

Groups
  • Pain
  • Perceived neg. outcomes
  • No Arthritis specific pgm
  • Weather
  • Dr. not mention

29
Additional Arthritis Specific Barriers among Non
Exercisers
  • Exer. Non-Ex
  • 17 67
  • 0 67
  • 0 50
  • 0 50

Groups
  • I cant
  • Lack pos. outcomes
  • Fear
  • Dr. not refer

30
Conclusions
  • PWA face both general and arthritis specific
    barriers to PA
  • Among PWA Exercisers and Non-exercisers face many
    of the same barriers
  • Exercisers less likely to allow barriers to
    prevent exercise
  • Exercisers modified their exercise
  • Non-Exercisers gave up exercise

31
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

32
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

33
Evidence-Based Interventions
  • Self Management Education Programs
  • Physical Activity/Exercise
  • Programs
  • Health Communications

34
Evidence-Based Interventions
  • Self Management Education Programs
  • Chronic Disease Self Management Program
  • Arthritis Self Management Program (Arthritis
    Foundation Self-Help Program aka ASHC)

35
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

36
Self Management Education
  • Chronic Disease Self Management Program (CDSMP)
  • Improved Outcomes 6 mo. 2 yrs.
  • Self efficacy v v
  • Self rated health v v
  • Disability v
  • Role activity v
  • Energy/fatigue v v
  • Health distress v v
  • MD/ER visits v v
  • Hospitalization v
  • Lorig et al 1999, 2001

37
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

38
Evidence-Based Interventions
  • Self Management Education Programs
  • CDSMP/ASMP
  • Physical Activity/Exercise Programs
  • Health Communications

39
Evidence-Based Interventions
  • Physical Activity/Exercise Programs
  • EnhanceFitness
  • Arthritis Foundation Exercise program (aka PACE)
  • Arthritis Foundation Aquatics Program

40
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

41
Physical Activity Interventions
  • EnhanceFitnessInitial 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

42
Arthritis Foundation Exercise Program
  • 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

43
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

44
AF Physical Activity/ Exercise Programs
45
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

46
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

47
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

48
Key Public Health Message
  • 30 minutes of moderate activity
  • At least 3 days per week
  • ACR consensus recommendations
  • Arth Rheum 200349 453-454
  • Can be done in 10 minute increments (makes it
    do-able)

49
Campaign Materials
  • Radio Spot
  • Recorded
  • Script for local live announcer
  • Brochure and Brochure Holder for pharmacies, MD
    offices churches, etc
  • Print PSAs
  • Posters

50
Themeline
Physical Activity. The Arthritis Pain
Reliever.
51
Campaign Materials
52
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

53
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

54
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

55
(No Transcript)
56
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

57
Evidence-Based Interventions
  • Self Management Education Programs
  • Chronic Disease Self Management Program
  • Arthritis Self Management Program (Arthritis
    Foundation Self-Help Program aka ASHC)
  • 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

58
Missouri Arthritis Program Collaboration with
Missouri Diabetes Program
Regional Arthritis Center
59
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).  
60
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.

61
Future Plans
  • Evaluation of general physical activity
    community-based 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.

62
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