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Health Care Provider Counseling for Weight Loss Among Adults with Arthritis and Overweight or Obesity — United States, 2002–2014


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Dana Guglielmo, MPH1,2; Jennifer M. Hootman, PhD1; Louise B. Murphy, PhD1; Michael A. Boring, MS1; Kristina A. Theis, PhD1; Brook Belay, MD3; Kamil E. Barbour, PhD1; Miriam G. Cisternas, MA1; Charles G. Helmick, MD1 (View author affiliations)

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Summary

What is already known about this topic?

Weight loss among adults with arthritis and overweight or obesity can improve pain, function, mobility, and health-related quality of life, and reduce disability.

What is added by this report?

From 2002 to 2014, the prevalence of health care provider counseling for weight loss among adults with arthritis and overweight or obesity increased by 10.4 percentage points from 35.1% to 45.5%.

What are the implications for public health practice?

Provider counseling for weight loss in adults with arthritis and overweight or obesity, along with other health behavior counseling, including physical activity and self-management education, might increase attempts at weight loss and eventual success.

The figure above is a visual abstract that details how excess weight can exacerbate joint pain, and therefore recommends weight loss to gain relief.
 

In the United States, 54.4 million adults report having doctor-diagnosed arthritis (1). Among adults with arthritis, 32.7% and 38.1% also have overweight and obesity, respectively (1), with obesity being more prevalent among persons with arthritis than among those who do not have arthritis (2). Furthermore, severe joint pain among adults with arthritis in 2014 was reported by 23.5% of adults with overweight and 31.7% of adults with obesity (3). The American College of Rheumatology recommends weight loss for adults with hip or knee osteoarthritis and overweight or obesity,* which can improve function and mobility while reducing pain and disability (4,5). The Healthy People 2020 target for health care provider (hereafter provider) counseling for weight loss among persons with arthritis and overweight or obesity is 45.3%. Adults with overweight or obesity who receive weight-loss counseling from a provider are approximately four times more likely to attempt to lose weight than are those who do not receive counseling (6). To estimate changes in the prevalence of provider counseling for weight loss reported by adults with arthritis and overweight or obesity, CDC analyzed National Health Interview Survey (NHIS) data.§ Overall, age-standardized estimates of provider counseling for weight loss increased by 10.4 percentage points from 2002 (35.1%; 95% confidence interval [CI] = 33.0–37.3) to 2014 (45.5%; 95% CI = 42.9–48.1) (p<0.001). Providing comprehensive behavioral counseling (including nutrition, physical activity, and self-management education) and encouraging evidence-based weight-loss program participation can result in enhanced health benefits for this population.

NHIS is an ongoing, in-person, cross-sectional survey of the civilian, noninstitutionalized population. CDC analyzed data on adults aged ≥18 years with arthritis and overweight or obesity from the Sample Adult component for 2002, 2003, 2006, 2009, and 2014 (24,275–36,697; response rate = 58.9%–74.3%). Having arthritis was defined as an affirmative response to the question “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” Body mass index (BMI), defined as weight (kg) divided by height (m2), was calculated from self-reported height and weight and categorized as: normal/underweight (<25); overweight (25 to <30); and obese (≥30). Obesity was further stratified into three BMI subgroups: class 1 (30 to <35); class 2 (35 to <40); and class 3 (≥40).** Provider counseling for weight loss, which was part of sponsored survey content featured in 2002, 2003, 2006, 2009, and 2014, was defined as an affirmative response to the question, “Has a doctor or other health professional ever suggested losing weight to help your arthritis or joint symptoms?”

All analyses accounted for the complex survey design; sampling weights were applied to make estimates representative of the U.S. civilian, noninstitutionalized population. Weighted numbers and age-standardized prevalences (using the projected 2000 U.S. population for ages 18–44, 45–64, and ≥65 years)†† were calculated for adults with overweight or obesity overall and for selected sociodemographic and health-related characteristics for 2002 and 2014. Results were declared significant if t-tests yielded p-values <0.05 for differences in age-standardized prevalences between 2002 and 2014, and between categories of characteristics in 2014.

Among the U.S. adult population, 28.3 million persons in 2002 and 38.9 million in 2014 had arthritis and overweight or obesity. From 2002 to 2014, the age-standardized prevalence of receiving provider counseling for weight loss among adults with arthritis and overweight or obesity increased by 10.4 percentage points from 35.1% (95% CI = 33.0–37.3) to 45.5% (95% CI = 42.9–48.1) (p<0.001) (Table), which met the Healthy People 2020 target of 45.3%. The prevalence increased by 5.7 percentage points for adults with arthritis and overweight (from 18.1% to 23.8%; p = 0.006) and 12.4 percentage points for those with obesity (50.4% to 62.8%; p<0.001). By obesity subgroup, the prevalence increased 11.8 percentage points among persons with class 1 obesity (40.8% to 52.6%; p<0.001) and 15.5 percentage points among those with class 3 obesity (69.0% to 84.5%; p<0.001); the increase among persons with class 2 obesity was not significant (Figure). In 2014 among adults with arthritis and overweight or obesity, the prevalence of receiving provider weight-loss counseling was significantly higher for females (versus males), those with obesity (versus overweight), those who had ever received provider counseling to engage in physical activity to manage arthritis (versus those who had not), those who had ever taken a self-management class or course (versus those who had not), and those with a primary care provider (versus those without one) (Table).

Discussion

From 2002 to 2014, the percentage of adults with arthritis and overweight or obesity who reported receiving provider weight-loss counseling increased by 10.4 percentage points. These improvements are encouraging; however, approximately 75% of adults with overweight and 50% of those with class 1 obesity are not receiving provider weight-loss counseling.

A recent report indicated that 61.0% of adults with arthritis received provider counseling for physical activity in 2014 (7), more than the 45.5% reported here for weight loss. Providers might advise for physical activity more frequently than weight loss because the former might be easier to discuss with patients or they might be more aware of the arthritis-specific benefits of physical activity. Findings of the current report indicate that those who are not receiving counseling for weight loss might also not be receiving counseling for physical activity. Nevertheless, to address obesity, the U.S. Preventive Services Task Force recommends that providers either provide or refer patients to intensive, multicomponent behavioral interventions that include management strategies (e.g., goal setting), dietary and physical activity changes, addressing barriers to change, self-monitoring, and strategies to maintain healthy behaviors.§§ The American College of Rheumatology also recommends that providers offer counseling for weight loss and physical activity to adults with hip or knee osteoarthritis. In randomized controlled trials, a combined exercise and diet intervention resulted in the greatest improvements in weight, pain, joint forces, inflammatory factors, and mobility compared with either intervention alone (4,8). In the current study, the percentage of adults with overweight or obesity who received weight-loss counseling was higher among those who had taken a self-management education course than among those who had not. Since the temporal sequencing of provider weight-loss counseling and taking a self-management education course (which includes weight-loss messages) cannot be delineated, this study could not determine whether provider counseling leads persons with arthritis and overweight or obesity to self-management education courses or vice versa. However, it is possible that persons with arthritis who receive recommendations for healthy behaviors, such as weight loss, from their provider are more amenable to engaging in other self-management behaviors, such as taking a self-management education course or engaging in physical activity.¶¶ One benefit of self-management education program participation is substantial increases in self-confidence (9), which is an important characteristic that can help adults with arthritis act on counseling to lose weight and be physically active. Combined counseling for weight loss, physical activity, and self-management education might enhance arthritis and other health outcomes.

Strategies to increase provider counseling for weight loss include health system interventions (e.g., electronic medical record clinical decision supports) and provider training. Electronic medical record clinical decision supports are effective in increasing the delivery of nutrition and physical activity counseling and decreasing BMI in children with obesity (10), and similar strategies might translate into weight loss in adult populations. Standardized electronic medical record clinical decision supports could assist provider counseling and referrals to evidence-based, community-delivered weight-loss and physical activity programs, intensive multicomponent interventions, or bariatric specialists, as well as facilitate patient education and help providers follow up on patients’ weight-loss goals and progress. Increased provider training regarding self-management support strategies can help providers to gain the skills and confidence to provide successful weight-loss counseling. Such training can include formal classroom instruction or use of publicly available online resources for counseling their patients.***,††† Many effective strategies, including motivational interviewing, the 5As approach (Assess, Advise, Agree, Assist, and Arrange), and emphasizing that small changes can have a big impact, are applicable to weight-loss counseling (6). For example, along with improving pain and mobility (4), a relatively small, but clinically significant, 5.1% reduction in weight over 20 weeks can significantly reduce functional disability in patients with knee osteoarthritis and obesity (5).

The findings in this report are subject to at least four limitations. First, NHIS data are self-reported and some characteristics might be susceptible to recall or social desirability bias. Specifically, the latter can lead to underestimation of BMI (2). Second, low response rates could also introduce response bias; however, sampling weights applied in the analysis include adjustment for nonresponse. Third, using BMI to classify overweight and obesity risks classifying some persons with a high muscle-to-fat ratio as having overweight or obesity, who might not require counseling. Finally, because 2014 data for provider counseling for weight loss were the most recent available, the prevalence might have changed since then.

Reported receipt of provider counseling for weight loss increased significantly among adults with arthritis and overweight or obesity from 2002 to 2014. Continuing this progress can ensure that the majority of adults in this population receive important messages that can increase their attempts to lose weight. Through combined counseling for weight loss, physical activity, and self-management education, and by making referrals to evidence-based programs, providers can help their patients with arthritis make meaningful improvements in quality-of-life and long-term health outcomes.

Conflict of Interest

No conflicts of interest were reported.

Corresponding author: Dana Guglielmo, dguglielmo@cdc.gov, 404-498-5453.


1Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Oak Ridge Institute for Science and Education (ORISE); 3Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC.


References

  1. Barbour KE, Helmick CG, Boring M, Brady TJ. Vital signs: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2013–2015. MMWR Morb Mortal Wkly Rep 2017;66:246–53. CrossRef PubMed
  2. Barbour KE, Helmick CG, Boring M, Qin J, Pan L, Hootman JM. Obesity trends among US adults with doctor-diagnosed arthritis 2009–2014. Arthritis Care Res (Hoboken) 2017;69:376–83. CrossRef PubMed
  3. Barbour KE, Boring M, Helmick CG, Murphy LB, Qin J. Prevalence of severe joint pain among adults with doctor-diagnosed arthritis—United States, 2002–2014. MMWR Morb Mortal Wkly Rep 2016;65:1052–6. CrossRef PubMed
  4. Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 2004;50:1501–10. CrossRef PubMed
  5. Christensen R, Bartels EM, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis 2007;66:433–9. CrossRef PubMed
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  7. Hootman JM, Murphy LB, Omura JD, et al. Health care provider counseling for physical activity or exercise among adults with arthritis—United States, 2002 and 2014. MMWR Morb Mortal Wkly Rep 2018;66:1398–401. CrossRef PubMed
  8. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013;310:1263–73. CrossRef PubMed
  9. Brady TJ, Murphy L, O’Colmain BJ, et al. A meta-analysis of health status, health behaviors, and healthcare utilization outcomes of the Chronic Disease Self-Management Program. Prev Chronic Dis 2013;10:120112. CrossRef PubMed
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TABLE. Age-standardized prevalence* of health care provider counseling for weight loss reported among adults aged ≥18 years with doctor-diagnosed arthritis and overweight or obesity, by selected characteristics — National Health Interview Survey, United States, 2002 and 2014Return to your place in the text
Characteristic 2002 2014 % change 2002 to 2014
Unweighted no. Weighted no. (x 1000) reporting counseling Age-standardized % (95% CI) Unweighted no. Weighted no. (x 1000) reporting counseling Age-standardized % (95% CI)
Overall 1,733 10,740 35.1 (33.0–37.3) 2,869 16,600 45.5 (42.9–48.1) 29.6§
Sociodemographic characteristics
Age group (yrs) (age-specific)
18–44 246 1,599 30.9 (27.4–34.6) 399 2,570 47.1 (42.6–51.5) 52.4§
45–64 858 5,629 41.9 (39.4–44.4) 1,297 8,046 45.5 (42.8–48.2) 8.6
≥65 629 3,513 36.4 (34.0–38.9) 1,173 5,984 40.6 (38.2–43.1) 11.5§
Sex
Male 592 4,444 31.3 (28.3–34.5) 1,028 6,670 41.1 (37.1–45.2) 31.3§
Female 1,141 6,297 38.6 (35.6–41.7) 1,841 9,930 49.2 (45.8–52.6) 27.5§
Race/Ethnicity
Hispanic 1,168 8,061 32.9 (30.5–35.4) 1,887 12,033 44.0 (40.9–47.1) 33.7§
White, non-Hispanic 322 1,590 45.2 (39.2–51.3) 515 2,263 47.4 (41.8–53.1) 4.9
Black, non-Hispanic 209 825 38.5 (32.5–44.9) 364 1,865 54.0 (46.9–60.8) 40.3§
Other, non-Hispanic 34 265 44.0 (31.3–57.5) 103 439 42.0 (28.9–56.4) −4.5
Education
Less than HS graduate 423 2,183 31.3 (26.7–36.3) 527 2,567 41.7 (35.4–48.2) 33.2§
HS graduate or equivalent 535 3,461 34.3 (30.6–38.3) 776 4,728 45.9 (40.8–51.0) 33.8§
Technical school/Some college 458 2,905 35.2 (31.5–39.0) 913 5,417 47.1 (42.6–51.6) 33.8§
College degree or higher 306 2,128 37.9 (32.9–43.1) 645 3,818 44.1 (38.9–49.4) 16.4
Work status
Employed 709 4,896 34.8 (32.0–37.8) 1,117 7,211 45.4 (42.1–48.7) 30.5§
Unemployed 33 191 25.5 (16.7–36.9) 111 697 45.8 (36.0–56.0) 79.6§
Unable to work/ Disabled 358 1,946 40.7 (35.5–46.1) 621 3,143 56.4 (50.2–62.4) 38.6§
Other 631 3,698 33.9 (27.2–41.3) 1019 5,546 39.6 (32.8–46.8) 16.8
Health-related characteristic
BMI (kg/m2)
Overweight (25 to <30) 482 3,023 18.1 (15.8–20.7) 743 4,352 23.8 (20.8–27.0) 31.5§
Obesity (≥30) 1,733 10,740 50.4 (47.3–53.6) 2,869 16,600 62.8 (59.6–65.9) 24.6§
  Class 1 (≥30 to <35) 600 3,756 40.8 (36.7–45.0) 959 5,708 52.6 (48.0–57.2) 28.9§
  Class 2 (≥35 to <40) 362 2,232 60.2 (54.7–65.4) 585 3,229 63.0 (56.3–69.2) 4.7
  Class 3 (≥40) 289 1,729 69.0 (60.6–76.3) 582 3,311 84.5 (80.2–88.0) 22.5§
Arthritis limitations
No 852 5,519 30.6 (28.1–33.2) 1,411 8,567 43.1 (39.8–46.4) 40.8§
Yes 878 5,206 42.5 (38.9–46.3) 1,457 8,029 48.7 (44.7–52.7) 14.6§
Ever counseled by provider to engage in physical activity to manage arthritis
No 351 2,219 15.7 (13.5–18.2) 400 2,294 17.5 (14.5–21.0) 11.5
Yes 1,373 8,481 51.7 (48.5–54.9) 2,467 14,304 60.5 (57.1–63.7) 17.0§
Ever taken a self-management class or course**
No 1,470 9,099 33.2 (31.0–35.5) 2,430 13,907 43.3 (40.6–46.1) 30.4§
Yes 262 1,639 50.7 (43.9–57.5) 439 2,693 61.5 (54.5–68.2) 21.3§
Joint pain severity††
None or mild (0–4) 328 2,207 32.8 (28.5–37.5) 607 3,655 45.8 (39.7–51.9) 39.6§
Moderate (5–6) 406 2,688 35.5 (31.1–40.2) 669 3,967 49.2 (43.8–54.6) 38.6§
Severe (≥7) 615 3,396 42.9 (39.0–46.8) 960 5,389 47.8 (42.7–53.0) 11.4
Self-rated health
Excellent/Very good 460 3,017 28.1 (25.1–31.4) 799 5,258 37.8 (33.7–42.0) 34.5§
Good 581 3,703 35.8 (31.9–39.9) 1,032 5,918 48.2 (43.6–52.8) 34.6§
Fair/Poor 692 4,021 45.7 (41.2–50.2) 1,037 5,419 55.1 (50.2–59.9) 20.6§
Smoking status
Current smoker 273 1,716 30.4 (26.7–34.4) 444 2,413 39.7 (34.7–44.9) 30.6§
Former smoker 635 4,137 36.2 (31.7–41.0) 961 5,705 48.4 (42.3–54.5) 33.7§
Never smoker 823 4,868 37.0 (33.9–40.3) 1,461 8,474 46.8 (43.3–50.4) 26.5§
Aerobic physical activity level§§
Active 509 3,490 33.9 (30.8–37.1) 941 5,715 42.2 (38.4–46.1) 24.5§
Insufficient 367 2,209 38.0 (32.9–43.4) 703 4,079 48.9 (43.1–54.9) 28.7§
Inactive 825 4,798 35.0 (31.7–38.5) 1,184 6,539 48.2 (43.5–52.8) 37.7§
Have a primary care provider
No 133 709 30.8 (25.5–36.7) 190 947 32.1 (26.6–38.1) 4.2
Yes 1,600 10,032 36.0 (33.7–38.4) 2,678 15,649 47.6 (44.8–50.5) 32.2§
No. of co-occurring chronic conditions¶¶
0 15 76 —*** 49 311 51.4 (35.6–66.9) —***
1–2 952 5,898 31.4 (29.1–33.8) 1,412 8,460 41.7 (38.7–44.7) 32.8§
≥3 766 4,767 49.4 (43.5–55.3) 1,408 7,829 52.8 (46.6–58.8) 6.9

Abbreviations: BMI = body mass index (kg/m2); CI = confidence interval; HS = high school.
* Estimates age-standardized to the 2000 U.S. standard population aged ≥18 years using three groups (18–44, 45–64, and ≥65 years).
Weighted number in thousands of adults with arthritis and overweight or obesity reporting counseling out of the total 28.3 million (2002) and 38.9 million (2014) adults with arthritis and overweight or obesity.
§ Difference is significant (p-value) at an α = 0.05 level.
Estimate potentially unreliable: relative standard error between 20%–30%.
** Based on response to the question “Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?”
†† Joint pain severity was categorized on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be.
§§ Respondents were classified as active if they reported ≥150 minutes of moderate intensity leisure time aerobic physical activity per week, insufficiently active if they reported 1–149 minutes, and inactive if they reported 0 minutes. Reported vigorous intensity physical activity minutes were counted double and added to moderate intensity physical activity minutes.
¶¶ Among these nine chronic conditions: asthma, cancer, diabetes, heart disease, hepatitis, hypertension, kidney disease, serious psychological distress, and stroke.
*** Estimate is suppressed because of unstable relative standard error >30.0%.

Return to your place in the textFIGURE. Age-standardized prevalence* of health care provider counseling for weight loss reported among adults aged ≥18 years with doctor-diagnosed arthritis and overweight or obesity, by year and body mass index (BMI) status — National Health Interview Survey, 2002, 2003, 2006, 2009, and 2014
The figure above is a scatter plot showing the age-standardized prevalence of health care provider counseling for weight loss reported among adults aged ≥18 years with doctor-diagnosed arthritis and overweight or obesity, by year and body mass index status, in the United States in 2002, 2003, 2006, 2009, and 2014.

* Estimates age-standardized to the 2000 U.S standard population aged ≥18 years using three age groups (18–44, 45–64, and ≥65 years).

The figure above is a scatter plot showing the age-standardized prevalence of health care provider counseling for weight loss reported among adults aged ≥18 years with doctor-diagnosed arthritis and overweight or obesity, by year and body mass index status, in the United States in 2002, 2003, 2006, 2009, and 2014.

Suggested citation for this article: Guglielmo D, Hootman JM, Murphy LB, et al. Health Care Provider Counseling for Weight Loss Among Adults with Arthritis and Overweight or Obesity — United States, 2002–2014. MMWR Morb Mortal Wkly Rep 2018;67:485–490. DOI: http://dx.doi.org/10.15585/mmwr.mm6717a2.

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