State-Specific Severe Joint Pain and Physical Inactivity Among Adults with Arthritis — United States, 2017

An estimated 54.4 million (approximately one in four) U.S. adults have doctor-diagnosed arthritis (arthritis) (1). Severe joint pain and physical inactivity are common among adults with arthritis and are linked to adverse mental and physical health effects and limitations (2,3). CDC analyzed 2017 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate current state-specific prevalence of arthritis and, among adults with arthritis, the prevalences of severe joint pain and physical inactivity. In 2017, the median age-standardized state prevalence of arthritis among adults aged ≥18 years was 22.8% (range = 15.7% [District of Columbia] to 34.6% [West Virginia]) and was generally highest in Appalachia and Lower Mississippi Valley regions.* Among adults with arthritis, age-standardized, state-specific prevalences of both severe joint pain (median = 30.3%; range = 20.8% [Colorado] to 45.2% [Mississippi]) and physical inactivity (median = 33.7%; range = 23.2% [Colorado] to 44.4% [Kentucky]) were highest in southeastern states. Physical inactivity prevalence among those with severe joint pain (47.0%) was higher than that among those with moderate (31.8%) or no/mild joint pain (22.6%). Self-management strategies such as maintaining a healthy weight or being physically active can reduce arthritis pain and prevent or delay arthritis-related disability. Evidence-based physical activity and self-management education programs are available that can improve quality of life among adults with arthritis.

BRFSS is an ongoing state-based, landline and cellular telephone survey of noninstitutionalized adults in the United States aged ≥18 years that is conducted by state and territorial health departments in 50 U.S. states, the District of Columbia (DC), and U.S. territories.^† The combined (telephone and cellular) median response rate in 2017 among states was 45.9% (range = 30.6%–64.1%); 435,331 adults reported information about arthritis status and age, and among them, 144,099 reported having arthritis.^§ Having arthritis was defined as a response of “yes” 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?” No/mild, moderate, and severe joint pain were defined by responses of 0–3, 4–6, and 7–10, respectively, to the question “Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. 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, during the past 30 days, how bad was your joint pain on average?” Physical inactivity was defined as a response of “no” to the question “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?”

All analyses, which accounted for BRFSS’s complex sampling design, were conducted using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0; RTI International). Sampling weights, using iterative proportional fitting (raking), were applied to make estimates representative of each state.^¶ Age-standardized,** state-specific prevalences of arthritis among adults aged ≥18 years, and of severe joint pain and physical inactivity among adults with arthritis, were calculated by selected characteristics. Differences across subgroups were tested using t-tests, and orthogonal linear contrasts were conducted for tests of trends to detect linear patterns in ordinal variables (4); all differences and trends reported in the text are significant (α = 0.05).

In 2017, age-specific arthritis prevalence was higher with increasing age, ranging from 8.1% among those aged 18–44 years to 50.4% among those aged ≥65 years (Table 1). Age-standardized arthritis prevalence was significantly higher among women (25.4%) than among men (19.1%); non-Hispanic American Indian/Alaska Natives (29.7%) than among other racial/ethnic groups (range = 12.8%–25.5%); and those unable to work/disabled (51.3%), compared with retired (34.3%), unemployed (26.0%), or employed/self-employed (17.7%). Arthritis prevalence was higher with increasing body mass index, ranging from 17.9% among those with healthy weight or underweight to 30.4% among those with obesity. Arthritis prevalence was lower among Hispanics and non-Hispanic Asians than among other racial/ethnic groups, was inversely related to education and federal poverty level, and was higher among those living in more rural areas compared with urban dwellers.

Among adults with arthritis, no/mild, moderate, and severe joint pain was reported by 36.2% (95% confidence interval [CI] = 35.7%–36.8%), 33.0% (CI = 32.4%–33.5%), and 30.8% (CI = 30.3%–31.4%) of respondents, respectively (unadjusted prevalences). Age-specific percentages for severe joint pain declined with increasing age, ranging from 33.0% among those aged 18–44 years to 25.1% among those aged ≥65 years. Age-standardized severe joint pain prevalence was ≥40% among the following groups: those unable to work/disabled (66.9%); those with less than a high school diploma (54.1%); those living at ≤125% federal poverty level (51.6%); non-Hispanic blacks (50.9%); retired persons (45.8%); Hispanics (42.0%); non-Hispanic American Indians/Alaska Natives (42.0%); and lesbian/gay/bisexual/queer/questioning (40.7%; reported by 27 states). Severe joint pain prevalence was similar across urban/rural geographic areas, ranging from 32.7%–35.7% in all areas, except for a lower prevalence (28.6%) in large fringe metro areas (Table 1).

Among adults with arthritis, age-specific physical inactivity prevalence was higher with increasing age (ranging from 31.0% among those aged 18–44 years to 37.0% among those aged ≥65 years). Age-standardized physical inactivity prevalence was ≥40% among the following groups: those unable to work/disabled (51.2%); those with less than a high school diploma (46.4%); those living at ≤125% federal poverty level (42.6%); and non-Hispanic blacks (40.4%). Physical inactivity prevalence increased with increasing rurality and with increasing joint pain levels (ranging from 22.6% among those with no/mild joint pain to 47.0% among those with severe joint pain).

Median age-standardized state prevalence of arthritis among adults aged ≥18 years was 22.8% (range = 15.7% [DC] to 34.6% [West Virginia]) (Table 2) and was highest in Appalachia and Lower Mississippi Valley regions. Among 144,099 adults with arthritis, median age-standardized state prevalences of severe joint pain and physical inactivity were 30.3% (range = 20.8% [Colorado] to 45.2% [Mississippi]) and 33.7% (range = 23.2% [Colorado] to 44.4% [Kentucky]), respectively. Age-standardized severe joint pain (Figure) and physical inactivity prevalences were highest in southeastern states.

Corresponding author: Dana Guglielmo, obx1@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, Oak Ridge, Tennessee; ³Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

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Abbreviations: CI = confidence interval; FPL = federal poverty level.
* Except for age groups, estimates were age-standardized to the 2000 projected U.S. population aged ≥18 years using three groups (18–44, 45–64, and ≥65 years): https://www.cdc.gov/nchs/data/statnt/statnt20.pdf.
^† Respondents were classified as having arthritis if they responded “yes” 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?” Overall, 144,099 respondents reported arthritis.
^§ Severe joint pain was defined as a response of 7–10 to “Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. 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, during the past 30 days, how bad was your joint pain on average?” Overall, 141,744 (98.4%) respondents with arthritis had severe joint pain data available.
^¶ Physical inactivity was defined as reporting “no” to the question “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?” Overall, 135,160 (93.8%) respondents with arthritis had physical inactivity data available.
** Categories might not sum to sample total because of missing responses for some variables.
^†† Among adults aged ≥18 years with arthritis.
^§§ Persons who identified as Hispanic might be of any race. Persons who identified with a racial group were all non-Hispanic.
^¶¶ Estimate is potentially unreliable because the relative standard error was between 20% and 30%.
*** Federal poverty level is the ratio of total family income to federal poverty level per family size. Overall, 35,648 respondents had missing data.
^††† Sexual orientation was not asked in every state. The 27 states that asked sexual orientation were California, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Mississippi, Montana, Nevada, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, Vermont, Virginia, Washington, and Wisconsin. A total of 1,049 respondents refused to answer.
^§§§ Urban-rural status was categorized using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties: https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf.

Abbreviations: CI = confidence interval; N/A = not applicable.
* Estimates were age-standardized to the 2000 projected U.S. population aged ≥18 years using three groups (18–44, 45–64, and ≥65 years).
^† Respondents were classified as having arthritis if they responded “yes” 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?”
^§ Severe joint pain was defined as a response of 7–10 to “Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. 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, during the past 30 days, how bad was your joint pain on average?”
^¶ Physical inactivity was defined as reporting “no” to the question “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?”
** Among adults aged ≥18 years with arthritis.

FIGURE. Age-standardized,* state-specific percentage of severe joint pain^† among U.S. adults aged ≥18 years with arthritis^§ — Behavioral Risk Factor Surveillance System, United States, 2017

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

^† Severe joint pain was defined as a response of 7–10 to “Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. 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, during the past 30 days, how bad was your joint pain on average?”

^§ Respondents were classified as having arthritis if they responded “yes” 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?”