Health Care Provider Counseling for Weight Loss Among Adults with Arthritis and Overweight or Obesity — United States, 2002–2014
Weekly / May 4, 2018 / 67(17);485–490
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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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.
†https://www.healthypeople.gov/2020/topics-objectives/topic/Arthritis-Osteoporosis-and-Chronic-Back-Conditions/objectives.
§§https://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care.
¶¶https://downloads.cms.gov/files/cmmi/community-basedwellnessrrevention-sixthmnthoutcomes-operationalcostrpt.pdf.
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