Hindawi Publishing Corporation

Arthritis
Volume 2013, Article ID 190868, 10 pages
http://dx.doi.org/10.1155/2013/190868

Research Article
Association of Body Mass Index with Physical Function and
Health-Related Quality of Life in Adults with Arthritis
Danielle E. Schoffman,1 Sara Wilcox,2,3 and Meghan Baruth3,4
1

Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina,
800 Sumter Street, Suite 216, Columbia, SC 29208, USA
2
Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 921 Assembly Street,
Columbia, SC 29208, USA
3
Prevention Research Center, Arnold School of Public Health, University of South Carolina, 1st Floor, 921 Assembly Street,
Columbia, SC 29208, USA
4
Department of Health Science, Saginaw Valley State University, 7400 Bay Road University Center, MI 48710, USA
Correspondence should be addressed to Sara Wilcox; [email protected]
Received 26 April 2013; Revised 4 October 2013; Accepted 7 October 2013
Academic Editor: Changhai Ding
Copyright 2013 Danielle E. Schoffman et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Arthritis and obesity, both highly prevalent, contribute greatly to the burden of disability in US adults. We examined whether body
mass index (BMI) was associated with physical function and health-related quality of life (HRQOL) measures among adults with
arthritis and other rheumatic conditions. We assessed objectively measured BMI and physical functioning (six-minute walk, chair
stand, seated reach, walking velocity, hand grip) and self-reported HRQOL (depression, stiffness, pain, fatigue, disability, quality
of life-mental, and quality of life, physical) were assessed. Self-reported age, gender, race, physical activity, and arthritis medication
use (covariates) were also assessed. Unadjusted and adjusted linear regression models examined the association between BMI and
objective measures of functioning and self-reported measures of HRQOL. BMI was significantly associated with all functional (s
0.007) and HRQOL measures (s 0.03) in the unadjusted models. Associations between BMI and all functional measures (s
0.001) and most HRQOL measures remained significant in the adjusted models (s 0.05); depression and quality of life, physical,
were not significant. The present analysis of a range of HRQOL and objective measures of physical function demonstrates the
debilitating effects of the combination of overweight and arthritis and other rheumatic conditions. Future research should focus on
developing effective group and self-management programs for weight loss for people with arthritis and other rheumatic conditions
(registered on clinicaltrials.gov: NCT01172327).

1. Introduction
Arthritis and other rheumatic conditions are the leading
cause of disability in adults in the United States [1]. The
negative consequences of arthritis and other rheumatic conditions, including pain, reduced physical ability, depression,
and reduced quality of life (QOL) can impact the physical
functioning and psychological well-being of those living with
the conditions [24]. A number of variables have been shown
to be associated with arthritis and other rheumatic conditions
such as older age, lower physical activity (PA) levels, female

gender, and being overweight or obese [5, 6]. Treatment of

arthritis and other rheumatic conditions are very costly for
insurers and patients alike [7], and given the growing number
of people in the United States over the age of 65, arthritis
and other rheumatic conditions are set to be an even larger
burden on the health care system in the coming years [5].
While about 47.8 million Americans self-reported doctordiagnosed arthritis and other rheumatic conditions in 2005,
this number is expected to reach about 67 million by 2030,
meaning that 25% of Americans will have arthritis and other
rheumatic conditions [8]. Without effective prevention and

2
treatment strategies, arthritis and other rheumatic conditions
will cause significant increases in the already high health care
costs weighing on Americans.
High body mass index (BMI) has been shown to be an
independent risk factor for arthritis and other rheumatic
conditions [6]. Individuals who are overweight or obese are
at a greater risk of developing arthritis and higher body
weight may also hasten the onset of some forms of arthritis
and other rheumatic conditions [6, 9]. A recent study using
data from the Behavioral Risk Factor Surveillance Survey
(BRFSS) found that the prevalence of arthritis and other
rheumatic conditions was highly related to BMI; of those with
arthritis, 25.9% were normal weight, 33.7% were overweight,
and 43.7% were obese [6]. Unfortunately, rates of obesity
continue to rise, with recent data showing that 33.3% of
American adults are overweight, and an additional 35.9% are
obese [10].
Past research has demonstrated a relationship between
arthritis and other rheumatic conditions and numerous
physical and psychosocial impairments, such as difficulty
with activities of daily living, decreased PA, impaired QOL,
and loss of quality-adjusted life years [2, 3, 11]. Additionally,
obesity has been shown to be associated with decreased
PA, decreased health-related quality of life (HRQOL), and
an increased risk of depression [1214]. However, a very
small number of studies have specifically looked at the
relationship between BMI and the symptoms of arthritis
and other rheumatic conditions in adults [3]. BMI was
shown to be associated with increased symptom severity and decreased QOL in a sample of participants with
fibromyalgia and decreased physical functioning in individuals with osteoarthritis [15, 16]. No studies to date have
examined the association between BMI and objectively measured, laboratory-tested physical function measures (e.g., sixminute walk and chair stand). Furthermore, studies have not
examined the relationship between BMI and various QOL
measures in diverse samples of adults with different types of
arthritis and other rheumatic conditions.
While the medical treatment for arthritis and other
rheumatic conditions varies widely by subtype, the public
health interventions for this disease utilize strategies that
are applicable regardless of arthritis type. The Centers for
Disease Control and Prevention (CDC) has validated a
case definition of arthritis for public health interventions
that has been used in BRFSS and the National Health
Interview Study (NHANES) since 1992 [17]. This definition
includes all community-dwelling adults with self-reported
doctor-diagnosed arthritis, including all types of arthritis
and rheumatic conditions [17]. In a recent article, arthritis
experts from the CDC urged researchers and practitioners
to work together to develop public health strategies to
reduce the burden of arthritis (as broadly defined by the
case definition), through strategies programs such as selfmanagement, weight loss, and PA promotion [17].
The purpose of this investigation is to describe the
relationship between BMI, objectively measured physical
function, and QOL-related measures in a racially diverse
sample of adults, representing a broad range of ages and
arthritis types. Using a large sample and a variety of

Arthritis
performance-based and self-report measures, we hypothesize
that individuals with a higher BMI will demonstrate poorer
performance on measures of physical function and report
greater impairments on self-reported QOL measures.

2. Methods
Data in this study are cross-sectional and were taken from
the baseline measurement visit (prior to randomization)
of participants enrolled in a randomized trial of two selfdirected programs for arthritis management. A priori power
calculations indicated that 300 participants were necessary
to detect small group differences (effect sizes = 0.23
0.38) with 80% power for the primary outcomes (e.g., pain,
fatigue, stiffness, and gait speed). To account for attrition
in the clinical trial, the recruitment goal was set at 400
participants. A number of strategies were used to recruit
participants into the study, with the most successful being
worksite listservs and newspaper advertisements. Interested
participants contacted the study office and completed a phone
screen to assess eligibility status.
Participants were adult community members with selfreported, doctor-diagnosed arthritis, and other rheumatic
conditions. Participants were eligible to take part in the
study if (1) they answered yes to the question: Have you
EVER been told by a doctor or other health care professional
that you have some form of arthritis, rheumatoid arthritis,
gout, lupus, or fibromyalgia? (this question uses the CDC
definition of arthritis and is used in the BRFSS) [17]; (2)
they reported at least one symptom of arthritis (joint pain,
stiffness, tenderness, decreased range of motion, redness and
warmth, deformity, crackling or grating, and fatigue); (3)
they were 18 years of age or older; (4) they are not diabetic
and taking insulin; (5) they did not have uncontrolled
hypertension; (6) they were able to participate in PA (as
measured by the Physical Activity Readiness Questionnaire
(PAR-Q)) [18]; (7) they were sufficiently inactive at the time
of enrollment (defined as engaging in <3 days per week of at
least 30 minutes of aerobic activity and <2 days per week of
at least 20 minutes of strength training).
Participants were ineligible if (1) they had a fall in the past
year that required medical assistance; (2) they were pregnant,
breastfeeding, or planning to become pregnant in the next
year (women); (3) they were a diabetic and taking insulin;
(4) they could not walk longer than 3 minutes without taking
a rest; (5) they could not stand without assistance for more
than 2 minutes; (6) they could not sit in chair without arms
for more than 5 minutes; (7) they were already physically
active (aerobic activities 3 days/week for 30 minutes/day
or strength training 3 days/week for 20 minutes/day). The
Physical Activity Readiness Questionnaire (PAR-Q) [18] was
also administered and participants endorsing any items, with
one exception, were excluded. Participants were not excluded
if they took medication for hypertension; however, they were
excluded if they had uncontrolled hypertension (160/100).
Of the initial phone inquiries ( = 1112), most participants completed a phone screen ( = 923), and about half
were eligible and interested in the project ( = 10 participants

Arthritis
were eligible but no longer interested) and were scheduled for
a baseline visit ( = 545); 401 of these participants completed
a baseline visit and were randomized to a self-management
program, whereas 135 did not attend their baseline visit, and
9 were excluded at the baseline visit prior to randomization
(7 for medical contraindications, 2 based on staff discretion).
The 368 participants deemed ineligible after the phone screen
were ineligible for a variety of reasons (e.g., regular exerciser
and medical condition). Full details about recruitment for
the randomized trial and the flow of participants have been
reported elsewhere [19].
Prior to the scheduled measurement session, participants
were mailed a survey that assessed sociodemographic characteristics; PA, dietary, and other health-related practices; QOL;
and arthritis-related characteristics. Participants brought the
completed survey to the session. Participants completed an
informed consent form that was approved by the Institutional
Review Board at the University of South Carolina. Upon
providing consent to participate, staff administered physical
measurements including height, weight, blood pressure, and
physical function tests; participants received a $20 cash
incentive from completion of the session. This study is
registered on clinicaltrials.gov, trial identifier: NCT01172327.
2.1. Measures
2.1.1. Sociodemographic/Health-Related. Participants reported their age, gender, race, the highest grade or years of education completed. Objectively measured height and weight were
obtained by trained staff. Body mass index was calculated as
kg/m2 using standard procedures and cut points [20].
2.1.2. Functional Exercise Capacity. The six-minute walk test
was used to measure functional exercise capacity. A 38 meter
walking course was marked with cones in a level, carpeted
hallway. Participants were instructed to walk as quickly as
possible (not run) for 6 minutes. They were allowed to use
their usual assistive devices during the test and were allowed
to slow down, stop, or rest as necessary. A staff member called
out the time every minute (e.g., you have 3 minutes to go) and
encouraged participants in a standardized manner using one
of two phrases, you are doing well or keep up the good
work. The score was the total distance walked (in meters) in
6 minutes. This test has been shown to be valid and reliable
[21, 22].
2.1.3. Lower Body Strength. Lower body strength was measured using the 30-second chair stand. Participants were
directed to sit in the middle of a standard chair with their back
straight, feet flat on the floor, with their hands on the opposite
shoulder crossed at the wrist. On the signal, participants rose
to a full stand and returned to a fully seated position, without
using their arms. One practice of 13 repetitions was followed
by one 30-second trial [23]. The score was the total number
of unassisted stands during the 30-second time frame. This
measure has been shown to be valid and have good test-retest
reliability in a sample of older adults [24].

3
2.1.4. Lower Body Flexibility. Lower body flexibility was
measured using the seated reach test. Participants removed
their shoes and sat on a raised mat with their legs extended,
knees straight, and feet positioned against a sit and reach box.
With their arms outstretched, hands overlapping, and middle
fingers even, participants slowly bent forward, reaching as far
forward as possible toward their toes and pushing a marker
forward. Assistive blocks were used (10, 20, and 30 cm) if
participants could not reach the zero position. Participants
were given 2 practice and 3 test trials. The score was the
total distance reached minus the assistive block (if used) to
the nearest 0.5 cm, using the best of the three trials. Higher
position scores are more favorable. This measure has shown
acceptable validity (for hamstring flexibility) in a sample of
middle-aged to older adults [25].
2.1.5. Gait. The GAITRite (CIR Systems, Havertown, PA), a
portable walking mat with software, was used to measure
kinematic parameters of the gait cycle. Participants walked
on the instrumented walkway without shoes at their normal
walking pace. Sufficient distance was provided at the start
and end of the walkway to insure a normal walking velocity.
Participants completed three test trials, and the three trials
were averaged. Participants needing an assistive device were
allowed to use it during data collection. The primary measure
of interest was gait speed, which was measured in centimeters/second but converted to meters/second. The GAITRite
has been previously validated with a three-dimensional
motion analysis system. A variety of gait parameters were
evaluated and showed an excellent level of agreement indicating the GAITRite system is a valid technique for quantifying
both averaged and individual parameters of gait [26]. Testretest reliability was found to be high across a number of
reported variables [27].
2.1.6. Upper Body Strength. Grip strength was measured
on the dominant hand using a Jamarhand dynamometer,
positioned in the no. 2 ring, (Lafayette Instruments, Lafayette,
IN) and was measured in kilograms. Participants stood with
their dominant arm at their side (not touching the body),
elbow bent to 90 degrees, wrist in the neutral position, and
thumb superior. On the signal, participants squeezed the
dynamometer with as much force as possible. No motivational coaching was provided during the trials. Participants
were given one practice and three tests (with a 1020 second
rest in between each) trials. The best of three trials was used
as the score. This measure has been shown to be reliable [28]
and valid [29].
2.1.7. Depressive Symptoms. The 10-item Center for Epidemiological Studies Depression Scale (CES-D) [3032] was
used to measure symptoms of depression. On a scale of 0
(rarely or none of the time) to 3 (most or all of the time),
participants rated the frequency with which they experienced
10 symptoms of depression during the past week. Responses
were summed to yield a score ranging from 0 to 30, with
a higher score indicating greater depressive symptoms. This
measure has been shown to be reliable and valid [31, 33, 34].

Arthritis

2.1.8. Symptoms of Arthritis: Pain, Fatigue, Stiffness. Using a

Visual Numeric Scale [35], participants rated their arthritis
symptoms in the past 2 weeks on a numeric scale from
0 (no symptoms) to 10 (severe symptoms). Separate items
were used to evaluate generalized pain, stiffness, and fatigue.
This measure has been shown to be sensitive to detecting
reduction in pain after the completion of an arthritis selfmanagement course [36].

the open-ended questions were coded and reclassified to the

above mentioned categories if applicable. Given the common
reporting of the use of disease-modifying antirheumatic
drugs (DMARDS) (in the open-ended question), an additional category of drugs was created. If participants reported
current use or at least one day of use of any one or more of
these six categories of drugs in the past 7 days, they were
considered to be using arthritis medication.

2.1.9. Disability. The 20-item Health Assessment Questionnaire (HAQ) Disability Index was used to measure disability
in eight categories of daily activities (i.e., dressing, arising,
eating, walking, hygiene, reach, grip, and common activities).
On a scale of 0 (without any difficulty) to 3 (unable to do),
participants reported the amount of difficulty they had in
performing two or three specific activities (in each category)
over the past week. Each of the eight categories was assigned
a score based on the highest score of any activity within
the category. If the category score was lower than a 2 but a
participant reported usually using a device or aid to perform
the activity, the score was increased to a 2. The total score
was the mean of the eight categories. Scores ranged from 0
to 3, with a higher score indicating higher impairment. This
measure has been shown to be valid [37] and reliable [38].

2.2. Analysis. Basic descriptive statistics included frequencies

and means of key survey, selected demographic, and healthrelated variables. Linear regression models examined the
relationship between BMI, physical functioning, and arthritis
symptoms. A separate model was conducted for each physical
function measure (six-minute walk test, 30-second chair
stand, seated reach, velocity, and grip strength) and each
HRQOL variable (depression, pain, fatigue, stiffness, HAQ
total, QOL, physical, and QOL, mental). Unadjusted models
were first run for all functional and HRQOL variables. Next,
adjusted models were run for the same dependent variables,
controlling age, gender, race (white, non-white), MVPA, and
arthritis medication use. PROC GLM was used to run all
regression models (SAS version 9.2; SAS Institute, Cary, NC,
USA). PROC GENMOD was used to run negative binomial
models for variables with nonnormal distributions. Results
of the negative binomial models were similar to those of
the linear regression models (in terms of direction and
significance of the results); thus, for the sake of simplicity and
ease of interpretation, linear regression results are reported
here. Analyses used a 0.05 level of statistical significance.

2.1.10. Quality of Life. The Centers for Disease Control and

Preventions 4-item Healthy Days Core Module measured
HRQOL [39]. Participants reported the number of days (in
the past 30) that their physical health was not good, their
mental health was not good, and the number of days that
poor physical or mental health kept them from doing usual
activities. The reliability and validity of this measure have
been previously established [39, 40].
2.1.11. Self-Reported PA. The Community Health Activities
Model Program for Seniors (CHAMPS) questionnaire, originally developed for older adults, is a 42-item self-report
measure of PA [41]. It includes activities typically undertaken
for exercise, activities undertaken in the course of ones day
that are physical in nature and recreational activities that
provide PA. For each item, participants reported whether or
not they had engaged in the activity in a typical week in the
past 4 weeks, the number of times per week, and the total
number of hours per week (in 6 categories ranging from less
than 1 hour a week to 9 or more hours per week). This
measure has been shown to be valid [42], have acceptable
test-retest reliability [42], and be sensitive to change [41].
Total hours per week of MVPA (3.0 METs) per week
were calculated. Calculations were based on the MET values
reported in the Ainsworth et al. [43] Compendium, adjusted
for the recommendations made by Stewart et al. [41].
2.1.12. Medication. Participants were asked to report if
they were currently taking Tylenol or acetaminophen,
nonsteroidal anti-inflammatory drugs (NSAIDS), COX-2
inhibitors, oral steroids, narcotic pain relievers, or any
other over-the-counter and prescription medications for
their arthritis (open-ended question). Medications listed in

3. Results
Table 1 presents demographic, weight status, physical function, and HRQOL variables for all participants ( = 401).
Participants ranged in age from 19 to 87 years, with a mean
age of 56.3 10.7 years. The sample was predominantly
female (85.8%), and a majority had a college degree (60.8%).
The average BMI was 33.1 8.3 kg/m2 and 56.9% were
obese (BMI 30 kg/m2 ) [43]. Table 2 presents the overall
model test, partial test for BMI, and model 2 for
each unadjusted and adjusted regression model measuring
the association between BMI and each of the functional
measures; Table 3 presents the models for the association
between BMI and each of the HRQOL measures. BMI was
significantly associated with all of the functional measures
(s 0.007) and all of the HRQOL measures (s 0.03)
in the unadjusted models. A higher BMI was associated with
more impaired scores for all functional and QOL measures,
with the exception of grip strength, where a higher BMI was
associated with greater grip strength. Associations between
BMI and all functional measures remained significant in the
adjusted models (s 0.001). Associations between BMI
and most of the QOL measures also remained significant in
the adjusted models (s 0.05); associations between BMI
and depression ( = 0.055) and QOL, physical ( = 0.15),
were no longer significant but approached significance in the
predicted direction.

Arthritis

Table 1: Baseline demographics, arthritis medication usage, weight status, physical function, and health-related quality of life measures
( = 401)a .
Demographic characteristics
Age, years
Gender
Men
Women
Race
White
African American
American Indian
Multiracial
Education
Less than a high school graduate
High school graduate or GED
Some colleges
College graduate
Employment status
Employed for wages
Self-employed
Out of work
A homemaker
A student
Retired
Unable to work
Arthritis medication usage
1 arthritis medication
Acetaminophen
NSAIDS
Steroids
Narcotics
DMARD
Weight status
BMI, kg/m2
Underweight (BMI < 18.5)
Normal weight (18.5 BMI < 25)
Overweight (25 BMI < 30)
Obese (BMI 30)
Physical activity
Hrs/wk of moderate to vigorous physical activity
Physical function measures
Six minute walk, m
Chair stands, no. stands
Seated reach, cm
Walking velocity, m/s
Grip strength, kg
Health-related quality of life
Depressionc
Stiffnessd
Paind
Fatigued
Disabilitye

% or mean (SD)b

Range

401
401
57
344
400
256
141
2
1
400
6
46
105
243
399
258
15
14
7
3
90
12
401
341
139
254
32
67
46

56.3 (10.7)

1987

401
1
58
114
228

33.1 (8.3)
0.25
14.5
28.4
56.9

15.860.7

401

3.4 (3.8)

025.5

399
401
399
397
401

494.1 (91.2)
10.0 (3.5)
21.7 (9.9)
1.1 (2.2)
27.1 (10.2)

151.5721.6
024.0
11.549.0
0.41.7
4.574.0

401
400
401
401
401

6.5 (5.1)
5.3 (2.5)
4.7 (2.3)
5.0 (2.6)
0.6 (0.5)

028.0
010.0
010.0
010.0
02.0

14.2
85.8
64.0
35.3
0.5
0.3
1.5
11.5
26.3
60.8
64.7
3.8
3.5
1.8
0.8
22.6
3.0
85.0
34.7
63.3
8.0
16.7
11.5

Arthritis
Table 1: Continued.

400
107
222
71
399
148
196
55

Quality of life, physical

0 days
1 day14 days
>14 days
Quality of life, mentalf
0 days
1 day14 days
>14 days

% or mean (SD)b
6.9 (9.1)
26.75
55.5
17.75
5.2 (7.9)
37.09
49.13
13.78

Range
030.0

030.0

Some s are less than 401 due to participant refusal to complete measure.
May not add to 100% due to rounding.
c
Scores range from 0 to 30, with higher score indicating greater depressive symptom.
d
Scores range from 0 to 10, with higher scores indicating more severe symptoms.
e
Scores range from 0 to 3, with high scores indicating higher impairment.
f
Scores range from 0 to 30, with higher score indicating more bad days.
b

Table 2: Unadjusted and adjusted associations between body mass index and physical function measures.

BMI coeff ()
Physical function measures
Six-minute walk
Chair stands
Seated reach
Walking velocity
Grip strength
a
b

5.16 (<0.0001)
0.10 (<0.0001)
0.36 (<0.0001)
0.009 (<0.0001)
0.17 (0.007)

Model 1a
Model ()
109.96 (<0.0001)
23.70 (<0.0001)
39.22 (<0.0001)
59.99 (<0.0001)
7.43 (0.007)

Model 2

BMI coeff ()

0.22
0.06
0.09
0.13
0.02

5.10 (<0.0001)
0.08 (0.0001)
0.35 (<0.0001)
0.009 (<0.0001)
0.16 (0.001)

Model 2b
Model ()
35.78 (<0.0001)
13.10 (<0.0001)
12.58 (<0.0001)
17.40 (<0.0001)
45.20 (<0.0001)

Model 2
0.35
0.17
0.16
0.21
0.41

Model 1: unadjusted; it contains only BMI (model df = 1).

Model 2: adjusted for age, gender, race, moderate to vigorous intensity physical activity, and arthritis drug usage (model df = 9).

4. Discussion
The impaired functioning caused by arthritis and other
rheumatic conditions can be debilitating, both physically and
mentally. Our findings suggest that being at an unhealthy
weight may further exasperate these impairments. BMI was
associated with greater impairments in a number of physical
function and QOL related measures, even after controlling
age, gender, race, MVPA, and arthritis medication use,
speaking to the robustness of these relationships.
Overall, BMI was highly associated with impaired physical function as measured by a variety of objective tests
of function. These functional tests measure physical ability
across a wide variety of domains, designed to measure the
capacity for independent functioning of the individual [23]. A
higher BMI was associated with shorter distances on the sixminute walk test, fewer chair stands, shorter seated reach, and
lower walking speed, demonstrating participants impaired
functional exercise capacity, lower body strength, flexibility,
and walking speed as compared to participants with a lower
BMI. The physical disability already experienced by many
suffering from arthritis and other rheumatic conditions
appears to be magnified by the additional burden of a higher
BMI. Higher levels of arthritis disability have been shown to
be linked to increased medical costs, hospital visits, comorbid
conditions, and other serious medical consequences [7, 8].

Together, these findings support the need for efforts aimed at

decreasing BMI among individuals with arthritis and other
rheumatic conditions.
A higher BMI was also associated with some measures
of HRQOL, including strong associations with higher selfreported pain, fatigue, stiffness, disability, and QOL, mental. Numerous studies have shown an association between
arthritis and lower HRQOL and disability [1, 44] in a smaller
range of measures, but the results of this study demonstrate
the widespread mental and physical impacts of BMI. In this
study, greater physical and mental impairments were found
among arthritic individuals with a higher BMI, across a
range of both objectively measured physical function and
self-reported measures of HRQOL.
Grip strength was the only functional measure to be
positively associated with BMI, a finding consistent with other
recent researches [45]. A recent study of grip strength in
the general population found that while a higher BMI was
related to greater grip strength in adults aged 30 to 70 years,
there was an inverse relationship among those over 70 years
of age, where a higher BMI was associated with lower grip
strength [46]. Associations between BMI and depression
and QOL, physical, were not statistically significant in the
adjusted models but approached significance in the predicted
direction. The relationship between BMI and QOL observed
in this study was not as strong as what has been observed in

Arthritis

7
Table 3: Unadjusted and adjusted associations between body mass index and health-related quality of life measures.

Health-related quality of life

Depression
Stiffness
Pain
Fatigue
Disability (HAQ total)
Quality of life, physical
Quality of life, mental
a
b

BMI coeff ()

Model 1a
Model ()

Model 2

0.07 (0.02)
0.07 (<0.0001)
0.05 (0.0003)
0.06 (<0.0001)
0.01 (0.0004)
0.12 (0.03)
0.12 (0.01)

5.16 (0.02)
23.81 (<0.0001)
13.42 (0.0003)
16.76 (<0.0001)
12.62 (0.0004)
4.62 (0.03)
6.00 (0.01)

0.01
0.06
0.03
0.04
0.03
0.01
0.01

BMI coeff ()

Model 2b
Model ()

Model 2

0.06 (0.055)
0.06 (<0.0001)
0.04 (0.007)
0.06 (0.0006)
0.01 (0.001)
0.08 (0.15)
0.1 (0.05)

4.19 (0.0004)
7.70 (<0.0001)
5.26 (<0.0001)
7.94 (<0.0001)
6.05 (<0.0001)
3.58 (0.002)
3.97 (0.0007)

0.06
0.11
0.07
0.11
0.08
0.05
0.06

Model 1: unadjusted; it contains only BMI (model df = 1).

Model 2: adjusted for age, gender, race, moderate to vigorous intensity physical activity, and arthritis drug usage (model df = 9).

other recent studies; for example, one study found that BMI
was independently related to impaired QOL in adults with
rheumatoid arthritis [3].
It is important to note that the definition of functional
measures used in the current study only represents a portion of what the World Health Organization (WHO) has
defined as physical function and the causes of disability [47].
The WHO published a framework for understanding the
determinants of disability, which includes body functions
and structure, and activity limitations and participation
restrictions [47]. All of these elements interact within the
context of the environment that the individual lives in, and it
is within this framework that the experience of disability can
be better understood [47]. The measures used in the present
study were all obtained at the level of body functions, thus
only capturing a part of the disability picture. It is possible
that the full impact of BMI-related disability for people with
arthritis and rheumatic conditions is more complex than
the measures we used. A recent study from the related field
of joint disease looked at posttotal hip replacement surgery
patients, examining the influence of overweight/obesity on
physical function and HRQOL but also looking at more
complex effects of complications and comorbidities [48]. The
results showed that while the influence of overweight/obesity
on physical function and HRQOL was minimal, there was
a substantial negative effect of postsurgical complications
and comorbidities [48]. This indicates the need to include
more variables to describe the complex relationships between
physical function and disability at multiple levels of influence,
including comorbidities, in order to best model its impact on
physical and emotional well-being.
Given that the prevalence of obesity and arthritis and
other rheumatic conditions continue to rise in the United
States, it is important that researchers and clinicians work
to find strategies to improve the QOL and level of functioning of affected individuals. Despite the high correlation
between being overweight and having arthritis and other
rheumatic conditions, few interventions have investigated the
links between the two conditions or offered suggestions for
future treatment programs. Some research has shown the
benefit of weight loss for the improvement of obesity-related
conditions, including the alleviation some of the symptoms

of arthritis [49]. Unfortunately, few overweight individuals

receive diet, exercise, or weight loss counseling from their
primary care physician [50]. One study targeting obese
individuals with arthritis found that only 43% received weight
loss counseling from their physician [9]. However, this study
also found that when individuals did receive weight loss
advice from their physician, they were more likely to lose
weight than those patients that did not receive the advice
[9]. Another study found that physician advice was independently associated with patient engagement in arthritis
self-management strategies of any kind [51]. These studies
demonstrate the influence physicians may have in arthritic
populations, perhaps making them an important partner in
interventions aimed at improving health behaviors in this
population.
In addition to weight loss, getting sufficient PA has been
recommended as an arthritis self-management strategy [51].
Increased PA could lessen the symptoms of arthritis and other
rheumatic conditions and promote weight loss. However,
often times, the pain, stiffness, and other symptoms that
accompany arthritis and other rheumatic conditions deter
people from being active [52]. On average, individuals with
arthritis are insufficiently active and are even less likely to be
active than people without arthritis [53]. It is possible that the
excess weight prevents some arthritic individuals from being
active; therefore, losing weight may actually lead to increases
in PA. Unfortunately, persons with arthritis have expressed
that there is a lack of exercise programs available that are
suitable to their specific needs [52]. One aim of the current
trial is to examine the effectiveness, safety, and participant
satisfaction with a self-directed PA program designed for
adults with arthritis. Results from this trial will provide
insight into what aspects of a program may be the most
acceptable in this population.
There is a paucity of research examining factors associated
with successful weight loss and increased PA in adults with
arthritis and other rheumatic conditions. Additional studies
examining these predictors would help researchers and clinicians develop more effective programs that meet the needs
of this at risk population. From a public health perspective,
effective group-based programs or low-cost self-management
programs are particularly appealing, as a large number of

8
people with arthritis and other rheumatic conditions could
be helped with relatively little resources.
Our findings should be interpreted in the context of some
recognized limitations. First, because this is a cross-sectional
study, we are unable to draw causal inferences and can only
suggest relationships between BMI and physical function and
HRQOL. Second, our study had an underrepresentation of
men, although our sample was similar to other recent arthritis
studies [3, 15]. National surveys show that women have higher
rates of arthritis than men, so the gender representation in
our sample is not surprising [8]. Finally, our sample was
limited to insufficiently active people, and it is possible that
the associations found between BMI and physical function
and HRQOL are not generalizable to physically active people
with arthritis and other rheumatic conditions. However, even
within our sample, there was a great deal of variability in
terms of PA participation. Despite these limitations, the
relationship observed between BMI and physical function
and HRQOL in this study offers evidence of the many areas
of life that might be affected by the combination of being
overweight and having arthritis and other rheumatic conditions. Strengths of the study sample include the relatively
large number of participants ( = 401), the age range of
participants (19 to 87 years), the use of objective measures
of physical functioning and BMI, and the variety of physical
function HRQOL measures collected.
In conclusion, BMI was strongly associated with physical
function and HRQOL measures in a sample of adults with
arthritis and other rheumatic conditions. With the rising
rates of obesity and arthritis and other rheumatic conditions, management strategies for both chronic conditions
are imperative. Physicians can aid in this effort by offering
more frequent support and advice for weight loss to their
overweight patients with arthritis to help avoid the disabling
combination of these conditions. Future research is needed
to develop effective group and self-management programs
for weight-loss in people with arthritis and other rheumatic
conditions.

Acknowledgments

Arthritis

[2]

[3]

[4]

[5]
[6]

[7]

[8]

[9]

[10]

[11]

[12]

They wish to thank Ellen Wingard, MSPH, R.D., L.D. and

Carol Rheaume, M.S., for their role in coordinating the
study. They would also like to thank the study participants and research investigators, staff, and students for their
important contributions. This work was supported by the
Centers for Disease Control and Preventions National Center
for Chronic Disease Prevention and Health Promotion by
Cooperative Agreement Number U48-DP-001936, Special
Interest Project (SIP) 09-028. The findings and conclusions
in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease
Control and Prevention or the Department of Health and
Human Services.

[14]

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