Disparities in Obesity and Related Conditions Among Americans with Disabilities

doi:10.1016/j.amepre.2013.02.021

American Journal of Preventive Medicine

Volume 45, Issue 1, July 2013, Pages 83-90

https://doi.org/10.1016/j.amepre.2013.02.021 Get rights and content

Background

Despite representing nearly 20% of the U.S. population, individuals with disabilities are invisible in obesity surveillance and intervention efforts.

Purpose

The current study (1) compares obesity and extreme obesity prevalence between Americans with and without disabilities and (2) examines the association between BMI category and weight-related chronic disease risk factors in both groups.

Methods

In 2012, six waves of data from the National Health and Nutrition Examination Survey (NHANES, 1999–2010) were pooled to compare the prevalence of obesity and extreme obesity between adults (aged ≥20 years, N=31,990) with disabilities (n=11,556) versus without disabilities (n= 20,434). Chronic disease risk factors (blood pressure, lipids, C-reactive protein [CRP], glucose) were compared across weight categories, by disability severity, and disability status.

Results

Obesity (41.6%) and extreme obesity (9.3%) prevalence among those with disabilities were significantly higher than they were among those without disabilities (29.2% and 3.9%, respectively). Disability severity and disability status negatively affected nearly all chronic disease risk factors. Additionally, there was a disability-by-weight interaction: people with disabilities at all weight categories were significantly more likely to report being told they had hypertension, high cholesterol, or diabetes and to have been prescribed antihypertensive and lipid-lowering medications.

Conclusions

The prevalence of obesity (41.6%) and extreme obesity (9.3%) found in individuals with disabilities is high. When compared to obese adults without disabilities, obese adults with disabilities are more likely to have diabetes, high cholesterol, hypertension, and higher CRP. Thus, the study provides convincing evidence of obesity-related health disparities between Americans with and without disabilities.

Introduction

Currently, 54 million Americans (~20% of the adult population) experience disability.¹ Disability prevalence is expected to increase² for several reasons, including (1) recent medical advances that have increased survival rates following traumatic injury, premature birth, and combat injuries incurred in Mideast conflicts (where those injured outnumber those killed³ by 7.5 to 1); (2) increased life expectancy for those born with disability or who acquire disability; and (3) aging of the “baby-boomer” generation. For all individuals, with or without disabilities, excess weight increases risk for chronic conditions such as type 2 diabetes, hypertension, hyperlipidemia, osteoarthritis, stroke, specific cancers, and metabolic syndrome; it also may limit physical function, independence, and productivity.⁴ However, individuals with disabilities are underserved by national efforts targeting surveillance, treatment, and prevention of obesity,⁵ even though this condition is thought to be more prevalent in those with disabilities compared to those without.⁶

Estimates from self-report data from the Behavioral Risk Factor Surveillance System7, 8 (BRFSS, 1998–1999, 2001–2003) and the National Health Interview Survey6, 9 (NHIS, 1994–1995, 2001–2005) reveal that the prevalence of obesity (BMI ≥30) is higher among individuals with disabilities (24.9%–31.6%) than without (15.1%–18.7%). However, these data likely underestimate prevalence, as individuals with disabilities, like their nondisabled counterparts,10, 11, 12, 13 tend to overestimate height and underestimate weight, resulting in lower BMI and obesity prevalence.¹⁴ Arguably, obesity prevalence estimates for people with disabilities should be based on measured height and weight data, such as those available from NHANES.

Since 1999, NHANES has conducted annual cross-sectional surveys of approximately 5000 individuals using a complex survey design to select participants representative of the non-institutionalized U.S. population. NHANES is the only ongoing national health survey that combines self-report interview data with physical examinations at a mobile examination center where anthropometric measures and laboratory data on disease risk factors are collected and includes questions to identify individuals with functional limitations. The purpose of the current study was to use NHANES data to compare obesity prevalence between individuals with disabilities and those without, and to assess the association between BMI category and weight-related chronic disease risk factors in both groups.

Section snippets

Methods

Data analyses were performed in June 2012 by pooling six waves of publicly available NHANES data (1999–2000, 2001–2002, 2003–2004, 2005–2006, 2007–2008, 2009–2010). Pooling data across years ensured an adequate sample size of adults (aged ≥20 years) with disabilities. Participants were classified as having mobility or nonmobility limitations based on self-report data using the schema of Rasch et al.¹⁵ Adults were identified as having a disability if they reported difficulty (some, much, or

Results

A total of 11,556 adults with disabilities and 20,434 adults with no disability were identified from six waves of NHANES data. Demographic characteristics of the study sample appear in Table 1. Adults with disabilities were older (59.4±0.3 years vs 41.3±0.2 years); more likely to be female (57.3% vs 50.0%); more likely to be white (75.8% vs 68.2%); had lower educational levels (27.6% vs 16.8% did not complete high school); had lower levels of annual household income (17.6% vs 35.2% earned

Discussion

These results confirm earlier findings that obesity is significantly more prevalent among individuals with disabilities than in the general population.6, 7, 9 The study also substantiated previous contentions that obesity prevalence among those with disabilities would likely be higher based on estimates derived from direct measures of height and weight rather than self-report.5, 21 Obesity (41.5%) and extreme obesity (9.3%) prevalence among individuals with disability from NHANES data were

Acknowledgments

No financial disclosures were reported by the authors of this paper.

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Cited by (55)

Obesity and Eligibility for Obesity Treatments Among Adults With Disabilities in the U.S.
2022, American Journal of Preventive Medicine
Citation Excerpt :
In an analysis of the 1994‒1995 National Health Interview Survey (NHIS), Weil and colleagues4 found a near twofold OR of obesity among adults with disabilities after adjustment for sociodemographic factors. The overrepresentation of obesity (as defined by a BMI ≥30 kg/m2) and severe obesity (BMI ≥40 kg/m2) among adults with disabilities has been supported by several subsequent analyses of the National Health and Nutrition Examination Survey (NHANES).5–7 The most recent available analysis included only older individuals (aged ≥60 years), reporting that the relative odds of functional impairment among those with obesity versus those without obesity increased from 1988–1994 to 1999‒2004 and plateaued from 1999–2004 to 2005‒2012.7
Obesity has been associated with disability; yet, the proportion who meet clinical criteria for obesity treatment among adults with disabilities remains poorly defined. Characterization of obesity and treatment eligibility by disability type may prioritize high-need groups. This study assessed the prevalence of obesity and eligibility for antiobesity pharmacotherapy and/or bariatric surgery in adults with disability.
This cross-sectional weighted analysis of the 2019 National Health Interview Survey, including self-reported health and sociodemographic information, was conducted in 2021. Burden of obesity defined by BMI and odds of meeting consensus criteria for antiobesity pharmacotherapy and/or surgery were calculated by functional disability type: vision, hearing, cognition, communication, mobility, and self-care.
From 29,170 community-dwelling adult respondents (59.1% response), the overall prevalence of disability was 10%. The prevalence of obesity among adults with a disability was 40.1% vs 30.5% for U.S. adults overall (p<0.0001). An estimated 17.1% with disability met the criteria for both bariatric surgery and antiobesity pharmacotherapy; another 39.8% were eligible for pharmacotherapy alone (vs 7.9% and 33.2%, respectively, for adults overall; p<0.0001). In fully adjusted models, disability was associated with greater ORs for mild obesity (OR=1.2; 95% CI=1.1, 1.4), moderate‒severe obesity (OR=2.1; 95% CI=1.8, 2.3), and criteria for bariatric surgery (OR=2.4; 95% CI=2.1, 2.7) and pharmacotherapy (OR=1.3; 95% CI=1.2, 1.4). Mobility, self-care, and cognition disabilities were associated with eligibility for bariatric surgery and antiobesity pharmacotherapy.
Individuals with disabilities have higher odds of obesity and eligibility for antiobesity treatments. Comorbidities should be considered, accommodations should be provided, and insurance coverage should be expanded to ensure access to antiobesity treatments for adults with disabilities.
Promoting nutrition equity for individuals with physical challenges: A systematic review of barriers and facilitators to healthy eating
2021, Preventive Medicine
Citation Excerpt :
Physical disabilities affect over one billion people internationally (UN World Health Organization (WHO), 2011), including one-quarter (26%) of all community-dwelling adults in the United States (US) (Okoro et al., 2018). As a commonly unrecognized health disparity population (Krahn et al., 2015), people with disabilities (PWD) experience higher rates of obesity, diabetes, cardiovascular disease, and other preventable co-morbidities relative to individuals living without a disability (Froehlich-Grobe et al., 2013). Higher rates of modifiable risk factors for chronic health conditions, such as poor nutrition, potentially play a strong role in these chronic disease disparities (Kimokoti and Millen, 2016).
Impaired mobility is the most common form of functional disability in the US, affecting one out of every sixteen working-age adults. Little is known about the barriers to and facilitators of healthy eating among people with impaired mobility (PWIM), who are at increased risk for diet-related chronic disease. The pathways by which impaired mobility influence dietary intake are unclear, yet likely involve a complex interplay between structural determinants of health and individual factors. To help advance nutrition equity initiatives for PWIM, this systematic review aimed to qualitatively synthesize factors associated with dietary intake across four levels of ecologic influence. An interprofessional team devised a comprehensive search strategy to identify these factors among working-age (18–64 years) PWIM. We queried Ovid MEDLINE, Web of Science, Scopus, and Embase via Ovid for articles published between January 1, 1990 and April 25, 2021. Twelve studies met our review criteria. We classified factors within one of four ecologic levels of influence: individual, social, environmental, and policy/program. Most studies disproportionately reported on personal level factors of influence, with less information on other levels of influence. This systematic review is an important first step for informing the design of evidence-based strategies to support healthy eating among PWIM. However, it also reveals a wide chasm in the needed information to adequately bridge structural determinants of this nutrition divide. More studies are needed that include rigorous measures of dietary intake and that aim to elicit how social, environmental, and policy-level factors contribute to dietary disparities among PWIM.
Group Lifestyle Balance Adapted for Individuals With Impaired Mobility: Outcomes for 6-Month RCT and Combined Groups at 12 Months
2020, American Journal of Preventive Medicine
Citation Excerpt :
Group Lifestyle Balance Adapted for Individuals with Impaired Mobility (GLB-AIM) was formally adapted from the Diabetes Prevention Program Group Lifestyle Balance program (DPP GLB)31–33 with guidance from a national advisory board, detailed elsewhere.34 The DPP GLB targets reducing diabetes risk, which people with mobility impairment experience at a higher prevalence than the general population.3 The authors opted to adapt this evidence-based program for people with mobility impairment because the DPP GLB (1) is a 12-month ILI that targets changes in dietary intake and increased PA; (2) has yielded strong data across diverse samples,30,35–37 different settings,38,39 and different platforms40; (3) offers the program materials online for free; and (4) delivers in-person training sessions.
This study examines the feasibility and effectiveness of an intensive lifestyle intervention adapted for people with impaired mobility.
This was a randomized, wait-list controlled trial. The experimental group immediately received the 12-month weight loss program; the wait-list control group received it after a 6-month delay. Between-group comparisons were conducted for the 6-month RCT study design. Repeated measures were conducted for both groups combined after receiving the 12-month intervention. Data were collected August 2015–February 2017 and analyzed in 2017.
A community-based sample received 23, group-based sessions via a mix of telephone and in-person sessions in a hospital-based setting. Participants with impaired mobility (n=66) were middle-aged (49.80 [SD=11.37] years), mostly White (66.7%), female (66.7%), and most commonly had spinal cord injury (47.0%).
The 12-month intervention delivered 23 group-based sessions that promoted weight loss through reducing caloric intake and increasing physical activity.
Primary outcomes were effectiveness measured as change in weight and time spent in moderate physical activity. Feasibility was assessed in 12-month combined group analyses, measured as retention, attendance, and dietary self-monitoring.
The 6-month RCT results showed that the immediate and delayed groups differed significantly (p<0.05) in weight (−1.66 [SD=4.42] kg loss vs 0.05 [SD=4.15] kg gain) and moderate physical activity (52.93 [SD=90.74] minutes/week increase vs −14.22 [SD=96.02] minutes/week decrease), accounting for baseline weight, time with disability, and age of onset. The 12-month results with groups combined demonstrated 74.2% retention and 77.7% core session attendance. Self-monitoring was higher in the delayed group (77.3%), who used a smartphone app, than the immediate group (47.3%), who mostly used paper trackers. Participants achieved significant 12-month weight loss of 3.31 (SD=10.13) kg (d=0.33) in mixed modeling analyses with groups combined yet did not significantly increase moderate physical activity.
Group Lifestyle Balance Adapted for Individuals with Impaired Mobility is a feasible, effective approach to teach healthy lifestyle skills to individuals with mobility impairment, yielding modest weight loss and enhanced self-efficacy.
This study is registered at www.clinicaltrials.gov NCT03307187.
Baseline Dietary Intake of Individuals with Spinal Cord Injury Who Are Overweight or Obese
2019, Journal of the Academy of Nutrition and Dietetics
Individuals with spinal cord injury (SCI) experience significant secondary health conditions including excess adiposity. Dietary guidelines for individuals with chronic SCI do not exist.
To describe baseline dietary intake and quality based on conformance with dietary recommendations in participants enrolled in GoHealthySCI, a weight loss intervention for individuals with SCI, which promotes lifestyle change.
Cross-sectional analyses were conducted on data collected from April through August 2017 in a randomized pilot study.
Thirty-seven participants enrolled in the study in Houston, TX. All participants were at least 1 year post injury with a self-reported body mass index (calculated as kg/m²) ≥23. The racially/ethnically diverse sample was predominantly male (n=23), average age was 41.8±13.5 years, and average number of years since injury was 18.1±14.9. Participants varied in terms of level of injury; 19 participants identified as having tetraplegia and 19 identified as having paraplegia.
The Automated Self-Administered 24-Hour Recall dietary assessment was used to obtain baseline dietary intake data. Participants reported food intake on 3 nonconsecutive days.
Descriptive statistics were conducted for the primary research objectives. Mean macronutrient and micronutrient intake and Healthy Eating Index-2015 total and component scores are described.
Average daily energy intake was 1618±434 kcal. Daily intakes of whole fruits (0.6±0.7 cups), vegetables (1.6±0.9 cups), and whole grains (15%) of total grains were lower than recommendations from the 2015-2020 Dietary Guidelines for Americans. Average daily fiber (15.0g±6.0) met the Academy of Nutrition and Dietetics Evidence Analysis Library minimum target range for individuals with SCI. All percentages of calories from macronutrients were within the acceptable macronutrient distribution ranges: total fat (34.3%±6.2%), protein (16.7%±4.2%), and carbohydrate (49.3%±8.4%). Mean Healthy Eating Index-2015 score was 54.4.
This study provides a description of dietary intake by individuals with SCI who are overweight or obese. Although macronutrients are within the acceptable distribution range, calories from fat are at the high end and those from protein are at the low end of those ranges. In addition, on average, individuals reported inadequate intake of fruits, vegetables, whole grains, fiber, seafood and plant protein, and healthy fats and excess intake of added sugars and saturated fat. Results provide preliminary evidence of dietary inadequacies and suggest that larger studies examining dietary intake are warranted.
Pilot randomized trial of a telephone-delivered physical activity and weight management intervention for individuals with lower extremity amputation
2019, Disability and Health Journal
Obesity and inactivity are common and burdensome for people with lower extremity amputation (LEA). The extent to which home-based physical activity/weight management programs are effective and safe for people with LEA is unknown. Translating effective interventions for understudied disability groups is needed.
To test the feasibility, acceptability, and safety of a weight management and physical activity intervention and obtain preliminary efficacy estimates for changes in weight, body composition, and physical functioning.
Eligibility criteria included: LEA ≥1 year prior, 18–69 years of age, overweight or obese and living in the Seattle area. The intervention arm received self-monitoring tools (e.g., pedometer, scale) and written materials, a single exercise counseling home visit by a physical therapist, and up to 11 telephone calls from a health coach over 20 weeks that involved motivational interviewing to set specific, attainable, and measurable goals. The self-directed control group received the same tools and materials but no home visit or coaching calls.
Nineteen individuals consented to participate, 15 were randomized (mean age = 56, 73% male, 80% transtibial amputation) and 11 completed 20-week follow-up assessments. The intervention was acceptable and safe. Coached participants had greater decreases in waist circumference (mean difference between groups over 20 weeks, baseline values carried forward: −4.3 cm, 95% CI -8.2, −0.4, p = 0.03) and fat mass (−2.1 kg, 95% CI -3.8, −0.4, p = 0.02).
The home-based intervention was promising in terms of efficacy, safety and acceptability. Inclusion of multiple trial centers and increased use of technology may facilitate recruitment and retention.
Effects of upper-body resistance exercise training on serum nesfatin-1 level, insulin resistance, and body composition in obese paraplegic men
2019, Disability and Health Journal
As a recently discovered adipokine, nesfatin-1 is conducive to insulin sensitivity, lipid profile, energy balance, and probably obesity.
The aim of the present study was to investigate the effect of upper-body resistance exercise training (RET) on nesfatin-1 levels, insulin resistance, lipid profile, and body composition in obese paraplegic men.
Twenty obese paraplegic men were randomly assigned into control and upper-body RET groups. Upper-body RET was performed for 8 weeks, 3 sessions per week at an intensity corresponding to 60–80% maximum amount of force that can be generated in one maximal contraction in 5 stations (bench press, seated rows, sitting lat pulldown, arm extension, and arm curls). Body fat percentage was determined according to 4-sites skinfold protocol of Durnin and Womersley and Siri equation. Obesity for spinal cord injury patients in the current study was set at BMI >22 kg/m². Data were statistically analyzed by paired and independent t-test (P < 0.05).
We found significant improvements in serum levels of nesfatin-1 (21.13%), insulin sensitivity (8.95%), and high-density lipoprotein (10.87%). Other lipid profile markers, i.e. low-density lipoprotein (4.32%), cholesterol (8.20%), and triglyceride (15.10%) reduced significantly after upper-body RET. Moreover, upper-body RET led to a significant reduction in body mass index (2.36%), body fat percentage (2.79%), and waist-to-hip ratio (2.40%).
Upper-body RET improved insulin sensitivity, lipid profile, and body composition in paraplegic men. Serum nefastin-1 may be a potential marker of success in weight management in this population.

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Research ArticleDisparities in Obesity and Related Conditions Among Americans with Disabilities

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

Am J Prev Med

Am J Prev Med

J Am Dietetic Assoc

Arch Phys Med Rehabil

Part I. Arch Phys Med Rehabil

Arch Phys Med Rehabil

Americans with disabilities: 2005. Current Population Reports, P70–117

The future of disability in America

Secondary conditions and aging with disability. In:

Obesity among adults with disabling conditions

JAMA

State-specific prevalence of obesity among adults with disabilities—eight states and the District of Columbia, 1998-1999

MMWR Morb Mortal Wkly Rep

Disability and health state chartbook, 2006: profiles of health for adults with disabilities

Disability and health in the U.S., 2001-2005

Validity of overweight and obesity in a nation based on self-report versus measurement device data

Eur J Clin Nutr

A comparison of direct vs. self-report measures for assessing height, weight, and body mass index: a systematic review

Obes Rev

Research Article
Disparities in Obesity and Related Conditions Among Americans with Disabilities