September 2009 | Back to Table of Contents

Clinical and Health Affairs

Arthritis as a Public Health Issue

By Pamela Van Zyl York, M.P.H., Ph.D., R.D., L.N., and Katherine Franken, M.P.H., R.D.

Abstract
Arthritis affects 46 million people in the United States and more than 900,000 people (23% of the adult population) in Minnesota. Although the prevalence of the disease is greater in older age groups, more than half of those affected are younger than 65 years of age. This article discusses the socioeconomic impact of arthritis, the way the disease interacts with other chronic conditions, and why it should be viewed and managed as a public health issue.

“Public health in the future will be increasingly about increasing the quality of life, not merely its length. Arthritis, with the pain and limitation it inflicts on millions of our people, young and old, sits right in the center of that future.”¹
—James Marks, senior vice president, Robert Wood Johnson Foundation

The term “arthritis” refers to more than 100 diseases and conditions affecting the joints, surrounding tissues, and other connective tissues. Symptoms include pain, aching, stiffness, or swelling in or around a joint.² Osteoarthritis is the most common form of arthritis and accounts for more than half of all cases. Certain inflammatory forms of arthritis such as rheumatoid arthritis or systemic lupus erythematosus can affect multiple organs and cause widespread symptoms.

Arthritis is often thought to be an inevitable part of aging. But it is not just a malady of the elderly, and its impact is great. Arthritis affects the young and the old alike, men and women, and people of all racial and ethnic backgrounds.³ It is also a disease with high costs both in terms of medical care and lost productivity.⁴

Although arthritis is rarely thought of in public health terms, it should be. It affects a large number of people and is treatable. Evidence-based interventions can help patients with arthritis improve or maintain function and quality of life.⁵ This article reviews the prevalence of arthritis in the United States and Minnesota, discusses its socioeconomic impact and its relationship with other chronic diseases, and describes what physicians and communities can do to help people with arthritis manage their disease and maximize their ability to live independent, productive lives.

Epidemiology

Arthritis affects 46 million adults in the United States or 21% of the adult population; it is the most common cause of disability in this country and among the leading conditions that limit people’s ability to work productively.^6,7 In Minnesota, an estimated 904,000 adults (23% of the adult population) report doctor-diagnosed arthritis (Figure).³ In addition, an estimated 5,000 Minnesota children have arthritis or a related rheumatic condition.⁸

Arthritis is more prevalent in women than men in all age groups both in Minnesota and the United States. Minnesota data for black and Hispanic adults show slightly lower prevalence rates compared with that of white adults, but these data should be interpreted with caution because of small sample size.³ The Minnesota Department of Health will be increasing the size of its survey population for the Behavioral Risk Factor Surveillance System in 2010; this will enable us to provide better estimates for population subgroups.

Although we do not have national survey data on the prevalence of specific forms of arthritis, we do have national estimates that have been derived from studies of smaller, defined populations (Table).⁹ Data from Olmsted County and the Rochester Epidemiology Project have contributed significantly to these estimates.¹⁰

Because U.S. adults are living longer and the number of people in older age groups is growing, the number of adults living with chronic conditions, including arthritis, will increase. By the year 2030, an estimated 67 million adults in the United States will have physician-diagnosed arthritis (a 16% increase from the number in 2007).11 The number of people with arthritis in Minnesota is projected to increase from 904,000 in 2007 to more than 1.2 million in 2030 (a 32% increase).¹¹

One factor that has a slight influence on the prevalence of arthritis in Minnesota is Lyme disease. The number of people affected is small, but Lyme disease as a cause of arthritis is often overlooked. Of the 1,239 Lyme disease cases reported in Minnesota in 2007, 244 resulted in Lyme disease-related arthritis.¹²

The Impact of Arthritis in Minnesota

Arthritis-related disability is serious and life-altering. When asked if their arthritis or joint symptoms limited them in any way from taking part in their work, leisure, and social activities, 38% of Minnesota adults with arthritis (342,000 people) said it did.³ In addition, adults in Minnesota who reported arthritis were more than three times as likely to report fair or poor health status as those who did not have the disease (23% as compared with 7%).³

Arthritis can interfere with a person’s ability to work and be productive. It is currently the third leading cause of work limitation in the United States.⁷ Nearly one in three Americans who report doctor-diagnosed arthritis also report an arthritis-related work limitation. In every state, people with work limitations attributed to arthritis are less likely to report being employed than working-age adults who are not affected or who have the disease but no work limitations. In Minnesota, 35% of working-age adults with arthritis (217,000 people ages 18 years to 64 years) report work limitations related to their disease.7 Certain occupations such as mining, construction, agriculture, and sectors of the service industry that are physically demanding are associated with increased prevalence of arthritis, particularly osteoarthritis.

The economic impact of arthritis in the United States is considerable. In 2003, the cost of arthritis and other rheumatic conditions was $128 billion, with medical expenses accounting for almost $81 billion of the total and lost earnings for more than $47 billion.⁴ To put this in perspective, this equals about 1.2% of the U.S. gross domestic product. Each year, arthritis results in 750,000 hospitalizations and 36 million outpatient visits. The increase in medical costs associated with arthritis is primarily the result of more people being treated for the disease rather than increases in the cost of treatment. Although the cost of prescription drugs has increased significantly per person, costs for hospital stays have decreased, making the per person cost for medical care relatively stable. In Minnesota in 2003, the cost associated with arthritis was nearly $2.2 billion, with medical care accounting for $1.5 billion of that and lost earnings for nearly $750 million.⁴

Arthritis and Other Conditions

The impact of arthritis is amplified when we consider that it frequently co-exists with other chronic conditions. Arthritis can affect the progress and outcome of other chronic conditions and other conditions can affect the progress and outcome of arthritis. People with arthritis are two to four times more likely than those without arthritis to have one or more chronic condition or risk factors for them.¹³ In Minnesota, more than half of adults with heart disease (54%) have arthritis, and nearly half of adults with diabetes (47%) have arthritis.³

In addition, risk factors for many other chronic conditions, such as being overweight or obese and physical inactivity, are common in people with arthritis. Thirty-eight percent of Minnesota adults with arthritis are overweight (having a body mass index [BMI] of 25 to 29.9) as compared with 34% of the general adult population; and 35% of those with arthritis are obese (having a BMI of 30 or greater) as compared with 22% of the general adult population.³ Fifteen percent of adults with arthritis are inactive, as compared with 10% of all Minnesota adults.⁵

Physical inactivity contributes to the pain, dysfunction, and disability associated with arthritis and also contributes to poor outcomes for people with diabetes, heart disease, and other chronic conditions.^14,15 Being physically active is important for people with arthritis because it helps them manage pain and maintain function and mobility; it is also important for helping them control their weight, lessen their chance of a fall, and reduce their risk of depression and other chronic conditions.¹ But having arthritis may make it difficult to be physically active. In addition, having co-morbidities makes it even more difficult to do so. Minnesota adults with diabetes or heart disease and arthritis are less active than those who do not have arthritis.³ Research shows that pain, fear of pain, and lack of information on how to exercise safely prevent people with arthritis from being physically active.¹

The interrelationships of diseases and lifestyle factors have a significant impact on health.^14,15 Therefore, it is important to consider the likelihood that a person with arthritis or any other chronic condition has other chronic diseases or risk factors for them and appropriately screen for co-morbidities.¹³ It is especially important for physicians and other health care providers to recognize that people with inflammatory arthritis, particularly rheumatoid arthritis, are at significantly increased risk for cardiovascular disease and sudden death from cardiac disease. Therefore, they should aggressively screen for and manage cardiovascular disease in patients with inflammatory arthritis.^10,16

Management of Arthritis

Although arthritis is widespread and has a significant economic impact, it has not been addressed as a public health issue, nor has it received the attention it deserves from the health care community. Many view arthritis as a disease to be tolerated—as an inevitable part of aging. Pharmacological treatments that have been able to arrest the progress of inflammatory rheumatic conditions continue to be developed, but effective medical interventions for osteoarthritis, particularly those that might delay or prevent the progression of the disease and the need for joint replacement, remain elusive.

From a public health perspective, three key strategies can reduce the impact of arthritis: self-management education, physical activity, and weight management. Self-management education programs have been proven to reduce pain and depression; delay disability; improve self-efficacy, physical function, and quality of life; and reduce health care costs.¹⁷ Appropriate physical activity decreases pain, improves function, and delays disability.⁵ Weight loss among those who are overweight or obese may be difficult to achieve, but it has been shown to positively affect osteoarthritis in the hip and knee.⁵ These interventions are underutilized. Only 16% of adults with arthritis in Minnesota report ever having taken a class to manage their arthritis, 30% report being told by their doctor to lose weight, and 54% said they were encouraged to exercise.³ We know that physician recommendations are important in motivating people to undertake change.

Physicians can encourage their patients to take part in specific activities that can make a difference in their arthritis. These include the evidence-based Arthritis Foundation Arthritis Self-Management Program and the Chronic Disease Self-Management Program, both of which were developed by the Stanford University Patient Education Research Center, and the Arthritis Foundation Exercise Program and Aquatic Program and the EnhanceFitness exercise program.⁵

These self-management education programs are offered in many communities. They involve participants in highly interactive small-group workshops where they develop skills to make lifestyle changes and identify ways to manage their symptoms and day-to-day care. These programs have been shown to be more effective than simply providing patients with information, and they have been proven effective in improving self-reported health status and health outcomes, and in reducing health care costs.¹⁷ They also have been evaluated for safety.¹⁷ The Minnesota Arthritis Program of the Minnesota Department of Health is working with a number of state and local partners to increase the availability of these programs throughout Minnesota.

In addition to encouraging patients to take part in self- management and exercise programs, physicians can support community efforts to change public policy and the built environment so that it is easier and safer for all members of the community, including those with arthritis, to be more physically active. And they can work to ensure that those efforts consider the special needs of people with chronic conditions. Changes related to increasing physical activity, eating healthy foods, and decreasing tobacco use will be implemented in Minnesota in the coming months as a result of the recently enacted health care reform legislation. The support of health care providers and organizations is key to ensuring the effectiveness of these community efforts.

Conclusion

Arthritis has a significant impact on Minnesotans of all ages. Although additional research is needed to identify effective treatments to manage morbidity and mortality from arthritis, community leaders and health care providers can take action now to help people maintain or improve their health status and quality of life and to control health care costs and reduce lost productivity. Physicians have a role to play in this. In addition to providing medical treatment, they can counsel patients to make lifestyle changes that will enhance their overall health as well as help them manage their arthritis symptoms, and they can direct patients to self-management education and physical activity programs that will increase the likelihood that they will make these changes. Physicians and other health care providers also can support the availability and accessibility of these programs in their communities. MM

Pamela Van Zyl York is the program director and Katherine Franken is a program specialist for the Minnesota Arthritis Program in the Minnesota Department of Health’s Division of Health Promotion and Chronic Disease.

References
1. National Center for Chronic Disease, Prevention and Health Promotion, Centers for Disease Control and Prevention. Targeting Arthritis. Improving quality of life for more than 46 million Americans. 2008.
2. Arthritis Foundation, Association of State and Territorial Health Officials, Centers for Disease Control and Prevention. National Arthritis Action Plan: A Public Health Strategy. Atlanta GA. 1999.
3. Minnesota Department of Health, Behavioral Risk Factor Surveillance System, 2007.
4. Yelin E, Cisternas M, Foreman M, Pasta D, Murphy L, Helmick C. National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions-United States 2003. MMWR. 2007;56(1):4-7.
5. Theis KA, Helmick CG, Hootman JM. Arthritis burden and impact are greater among U.S. women than men: intervention opportunities. J Womens Health. 2007;16(4):441-53.
6. Brault M, Hootman J, Helmick C, Theis K, Armour B. Prevalence and most common causes of disability among adults—United States, 2005. MMWR. 2009;58(16):421-6.
7. Theis KA, Murphy L, Hootman JM, Helmick CG, Yellin E. Prevalence and correlates of arthritis-attributable work limitation in the US population among persons 18-64: 2202 National Health Data Survey. Arthritis Rheum. 2007;57(3):355-63.
8. Sacks JJ, Helmick CG, Luo YH, Illowite NT, Bowyer S. Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001-2004. Arthritis Rhem. 2007;57(8):1439-45.
9. Helmick C, Felson D, Lawrence R, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part I. Arthritis Rheum. 2008;58(1):15-25.
10. Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther. 2009;11:229-45.
11. Hootman J, Bolen J, Helmick C, Langmaid G, Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2003-2005, MMWR 2006;55(40):1089-92.
12. Minnesota Department of Health. Lyme Disease Surveillance and Prevention Project. 2007.
13. Murphy L, Bolen J, Brady T, Helmick C. Co-morbidities and chronic disease risk factors are very common among people with arthritis. Abstract presented at the 20th National Conference on Chronic Disease Prevention and Control, February 23-25, 2009. National Harbor, Maryland.
14. Bolen J, Murphy L, Greenlund K, et al. Arthritis as a potential barrier to physical activity among adults with heart disease—United States, 2005 and 2007. MMWR. 2009;58(7):165-9.
15. Bolen J, Hootman J, Helmick C, Murphy L, Langmaid G, Casperson C. Arthritis as a potential barrier to physical activity among adults with diabetes—United States, 2005 and 2007. MMWR. 2008;57(18):486-9.
16. Gabriel SE. Why do people with rheumatoid arthritis still die prematurely? Ann Rheum Dis. 2008;67(suppl III):ii30-4.
17. Lorig KR, Ritter P, Stewart AL. Chronic disease self-management program: 2-year health status and healthcare utilization outcomes. Medical Care. 2001;39(11):1217-23.