# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 2 {#section-1 .Chapter-#}

# Arthritis, Osteoporosis, and Chronic Back Conditions

Co-Lead Agencies: Centers for Disease Control and Prevention\
National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 2-3](#goal)

[Overview Page 2-3](#overview)

[Issues and Trends Page 2-3](#issues-and-trends)

[Disparities Page 2-6](#disparities)

[Opportunities Page 2-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
2-9](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
2-10](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
2-11](#healthy-people-2010-objectives)

[Arthritis and Other Rheumatic Conditions Page
2-11](#arthritis-and-other-rheumatic-conditions)

[Osteoporosis Page 2-17](#osteoporosis-1)

[Chronic Back Conditions Page 2-20](#chronic-back-conditions-1)

[Related Objectives From Other Focus Areas Page
2-21](#related-objectives-from-other-focus-areas)

[Terminology Page 2-22](#terminology)

[References Page 2-23](#references)

## Goal

Prevent illness and disability related to arthritis and other rheumatic
conditions, osteoporosis, and chronic back conditions.

## Overview

The current and projected growth in the number of people aged 65 years
and older in the United States has focused attention on preserving
quality of life as well as length of life. Chief among the factors
involving preserving quality of life are the prevention and treatment of
musculoskeletal conditions---the major causes of disability in the
United States. Among musculoskeletal conditions, arthritis and other
rheumatic conditions, osteoporosis, and chronic back conditions have the
greatest impact on public health and quality of life.

Demographic trends suggest that people will need to continue working at
older ages (for example, beyond age 65 years), increasing the adverse
social and economic consequences of the high rates of activity
limitation and disability of older persons with these conditions. At the
same time, effective public health interventions exist to reduce the
burden of all three conditions. (See Focus Area 6. Disability and
Secondary Conditions.)

### Issues and Trends

#### Arthritis

The various forms of arthritis affect more than 15 percent of the U.S.
population---over 43 million persons---and more than 20 percent of the
adult population, making arthritis one of the most common conditions in
the United States.[^1]**^,^** [^2]**^,^** [^3]**^,^** [^4]

The significant public health impact of arthritis is reflected in a
variety of measures. First, arthritis is the leading cause of
disability.[^5] Arthritis limits the major activities (for example,
working, housekeeping, school) of nearly 3 percent of the entire U.S.
population (7 million persons), including nearly 1 out of every 5
persons with arthritis.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
Arthritis trails only heart disease as a cause of work disability.[^6]
As a consequence, arthritis limits the independence of affected persons
and disrupts the lives of family members and other caregivers.

Second, health-related quality-of-life measures are consistently worse
for persons with arthritis, whether the measure is healthy days in the
past 30 days, days without severe pain, "ability days" (that is, days
without activity limitations), or difficulty in performing personal care
activities.[^7]**^,^** [^8]

![](media/image2.wmf){width="4.510416666666667in"
height="5.15625in"}Third, arthritis has a sizable economic impact.
Arthritis is the source of at least 44 million visits to health care
providers, 744,000 hospitalizations, and 4 million days of hospital care
per year.Error: Reference source not found**^,^** [^9] Estimated medical
care costs for persons with arthritis were \$15 billion, and total costs
(medical care plus lost productivity) were \$65 billion in 1992.[^10]
This latter amount is equal to 1.1 percent of the gross domestic
product. Nearly 60 percent of persons with arthritis are in the
working-aged populationError: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
and they have a low rate of labor force participation.[^11]

Fourth, arthritis, like other chronic pain conditions, has an important
negative effect on a person's mental health.[^12]**^,^** [^13]

Fifth, although death is not a frequent outcome of arthritis, persons
with certain forms of arthritis have higher death rates than the general
population. For example, the 2 million persons in the United States with
rheumatoid arthritis are at greater risk of premature death from
respiratory and infectious diseases than the overall U.S.
population.[^14]

A variety of demographic trends indicate that the impact of arthritis
will only increase.[^15] Given current population projections, arthritis
will affect over 18 percent of all persons in the United States (nearly
60 million persons) in the year 2020 and will limit the major activities
of nearly 4 percent (11.6 million).Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
Direct and indirect costs are expected to rise proportionately.

#### Osteoporosis

About 13 to 18 percent of women aged 50 years and older and 3 to 6
percent of men aged 50 years and older have osteoporosis, a reduction in
bone mass or density that leads to deteriorated and fragile bones. These
rates correspond to 4 million to 6 million women and 1 million to 2
million men in the United States who have osteoporosis.[^16] Another 37
to 50 percent of women aged 50 years and older and 28 to 47 percent of
men of the same age group have some degree of osteopenia, reduction in
bone mass that is not as severe as osteoporosis.

The major health consequence of osteoporosis is an increased risk of
fractures. Approximately 1.5 million fractures per year are attributed
to osteoporosis.[^17] One in three women and one in eight men aged 50
years and older will experience an osteoporotic-related fracture in
their lifetime.Error: Reference source not found Health care costs for
these fractures are estimated at \$13.8 billion per year in 1996
dollars.[^18]

The risk of any fracture increases with the presence of osteoporosis,
but hip fractures represent the most serious impact in terms of health
care costs and consequences for the individual. In 1994, there were
281,000 hospital discharges for hip fracture among people aged 45 years
and older. Of these, 74,000, or 26 percent, were among men.Error:
Reference source not found In all, 1 out of 6 white women and 1 out of
17 white men will experience a hip fracture by the time they reach age
90 years.[^19] Although the hip fracture rate among women seems
relatively constant, the rate among men seems to be increasing over
time.[^20]

An average of 24 percent of hip fracture patients aged 50 years and
older die in the year following fracture, with higher death rates among
men than among women.[^21] Also, hip fracture is more likely to lead to
functional impairment than are other serious medical conditions,
including heart attack, stroke, and cancer.Error: Reference source not
found For example, half of all hip fracture patients will be unable to
walk without assistance.Error: Reference source not found

#### Chronic Back Conditions

Chronic low back pain is described in different ways, such as the
occurrence of back pain lasting for more than 7 to 12 weeks, back pain
lasting beyond the expected period of healing, or frequently recurring
back pain. Moreover, a wide range of outcome measures are used to
describe chronic back problems, such as low back pain (LBP), activity
limitation, impairment, and disability. Compounding the problem is the
lack of a single data source to track chronic back problems. Sources
that have been used include workers compensation data, Occupational
Safety and Health Administration and Bureau of Labor Statistics records,
and data from national health surveys.

Chronic back conditions are both common and debilitating. Back pain
occurs in 15 to 45 percent of people each year,[^22]**^,^** [^23]**^,^**
[^24]**^,^** [^25]**^,^** [^26] and 70 to 85 percent of people have back
pain some time in their lives. In the United States, back pain is the
most frequent cause of activity limitation in people under age 45
years,[^27]**^,^** [^28] the second most frequent reason for physician
visits, the fifth-ranking reason for hospitalization, and the third most
common reason for surgical procedures.[^29]

Work-related risk factors, such as heavy physical work, lifting and
forceful movements, awkward postures, and whole body vibration, are
associated with low back disorders. Work-related risk factors account
for 28 to 50 percent of the low back problems in an adult
population.[^30] A number of personal factors may be risk factors for
low back pain. These include nonmodifiable factors, such as age and
gender, some anthropometric characteristics (for example, height and
body build), history of low back problems, and spinal abnormalities as
well as modifiable factors, such as weight, physical fitness, smoking,
some aspects of lumbar flexibility, trunk muscle strength, and hamstring
elasticity. A history of low back problems is one of the most reliable
predictors of subsequent back problems.[^31]

### Disparities 

Arthritis is a leading health problem among all demographic groups,
although significant and sometimes surprising disparities exist.
Arthritis affects 50 percent of people aged 65 years and older. However,
most people with arthritis are younger than age 65 years and of working
age.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
Arthritis also affects 285,000 children,[^32] making it one of the more
common chronic conditions of childhood. Arthritis is more common in
women aged 18 years and older than in men and is the leading chronic
condition and cause of activity limitation among women.[^33]**^,^**
[^34]

Whites and African Americans have similar rates of disease, but African
Americans have greater rates of activity limitation.Error: Reference
source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
For African Americans, arthritis is the third most common chronic
condition and the leading cause of activity limitation.[^35] For
Hispanics and American Indians or Alaska Natives, arthritis is the
second most common chronic condition and the second leading cause of
activity limitation.Error: Reference source not found For Asians or
Pacific Islanders, arthritis is the fourth most common chronic condition
and the second leading cause of activity limitation.Error: Reference
source not found For whites, arthritis is the most common chronic
condition and the second leading cause of activity
limitation.**^Error:\ Reference\ source\ not\ found^**

The rate of arthritis and its associated disabilities is higher among
persons with low education and low income.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
African Americans have lower rates of total joint replacement, a
surgical procedure that is highly successful in reducing the impact of
arthritis in persons with severe pain or disability, than do
whites.[^36] Certain types of jobs, such as shipyard work, farm work,
and occupations that place high knee-bending demands on workers,
increase the risks for osteoarthritis.[^37]**^,^** [^38]

Osteoporosis is more common among women than men. The rates of disease
increase markedly with increasing age. Rates are higher among
non-Hispanic white Americans than among Mexican Americans or
non-Hispanic African Americans.Error: Reference source not found White
postmenopausal women are at highest risk of the disease.

The risk for chronic back pain increases with age. Although back pain
appears to be equally common in men and women, impairment from back and
spine conditions is more common in women.

### Opportunities

The importance of physical activity for bone and joint health was
highlighted in a 1996 report *Physical Activity and Health: A Report of
the Surgeon General*.[^39] Although behavioral interventions seem to
have potential benefits, risk factors for the various types of arthritis
need to be identified. Recreational or occupational joint injury has
been identified as a risk factor for later osteoarthritis, and
overweight is a risk factor for osteoarthritis of the knee and possibly
the hip and hand.[^40] Overweight appears to be a risk factor associated
with the progression and severity of osteoarthritis.Error: Reference
source not found**^,^** [^41]

Genetic research may soon identify persons at high risk for certain
types of arthritis and thereby offer a better target for interventions.
Current medical care offers considerable relief from pain and other
symptoms for all types of arthritis. Available interventions often are
not used, however, because of the popular belief that arthritis is part
of normal aging, that a person can do nothing about it, and that it
affects only old persons. However, early diagnosis and aggressive
treatment of rheumatoid arthritis with disease-modifying drugs, for
example, appear to reduce its symptoms and related
disability.[^42]**^,^** [^43]**^,^** [^44]**^,^** [^45]**^,^**
[^46]**^,^** [^47]

Educational and behavioral interventions also can relieve symptoms and
reduce disability. Telephone contacts with clinicians and several
land-based and water exercise programs have had beneficial
outcomes.[^48]**^,^** [^49]**^,^** [^50]**^,^** [^51] The Arthritis
Self-Help Course, a 6-week, 2-hour per week educational intervention,
has been shown to reduce pain up to 20 percent beyond what was achieved
through conventional medical care.[^52] The course has the additional
benefit of reducing medical care costs by reducing the number of
physician visits for arthritis.Error: Reference source not found**^,^**
[^53] These and other effective interventions currently are underused,
with some reaching less than 1 percent of target populations.[^54]
Countering myths about arthritis and applying available interventions
can help reduce the impact of this health problem. (See Focus Area 6.
Disability and Secondary Conditions.)

Interventions for osteoporosis and fractures can be designed to prevent
the development of the disease, reduce further bone loss after the
occurrence of the disease, and lessen the risk of fractures.
Opportunities for primary prevention occur throughout the lifespan and
include programs to promote exercise, avoid smoking, reduce excessive
alcohol consumption, and improve nutrition, particularly the amount of
calcium and vitamin D in the diet. (See Focus Area 19. Nutrition and
Overweight.) These approaches may be important in achieving a high peak
bone mass during adolescence to delay the onset of osteoporosis as bone
mass declines with age. The approaches also may reduce the rate of bone
loss later in life.

Women need to be particularly concerned about bone loss occurring at the
time of menopause, when bone can be lost at the rate of 2 to 4 percent
per year. Women should be counseled on methods to minimize their bone
loss. Evidence indicates that older persons, even those who have had a
fracture, can benefit from treatment to prevent further bone loss or
restore some lost bone to decrease the risk of subsequent
fractures.[^55]

A wide range of interventions prevent or reduce low back problems. These
interventions may include activities designed to reduce the physical
demands of work activities by redesigning the task or to address the
individual's specific needs, such as strength or endurance training or
counseling for nutrition and lifestyle changes. Ergonomic interventions
that are directed at changing the job or work environment have proved
effective in reducing risk of occupational low back pain. (See Focus
Area 20. Occupational Safety and Health.) Thus, it is reasonable to
assume that ergonomic approaches would be effective in preventing
chronic LBP as well. Even in a nonwork environment, the physical demands
of an activity can be reduced by using ergonomic principles.
Interventions involving training in proper lifting techniques, physical
conditioning, and weight loss have been investigated in programmatically
oriented studies. These have shown that workplace interventions may have
an effect on low back disorders.[^56] The overall benefits of exercise,
nutrition, and lifestyle changes on an individual's health and
well-being would certainly justify efforts in this area. Also,
interventions directed at improving strength and endurance may have an
important impact on reducing activity limitations due to chronic LBP.

Because national data systems will not be available in the first half of
the decade for tracking progress, four subjects of interest concerning
arthritis and osteoporosis are not covered in this focus area's
objectives. Representing a research and data collection agenda for the
coming decade, the topics involve appropriate management, patient
education, provider counseling, and bone fracture prevention. The first
addresses persons with systemic rheumatic disease who receive an early
specific diagnosis and appropriate management plan. The second topic
concerns hospitals, managed care organizations, and large group
practices that provide effective, evidence-based arthritis education
(including information about community and self-help resources) for
patients to use as an integral part of the management of their
condition. The third topic concerns health care provider counseling for
persons at risk for or who have arthritis. Women aged 65 years and older
who are eligible under Medicare criteria to have an initial bone density
measurement are the focus of the fourth topic about bone fracture
prevention.

## Interim Progress Toward Year 2000 Objectives

The national health objectives for the year 2000 included two objectives
for osteoporosis, one objective for chronic back conditions, and no
objectives for arthritis. The objective of increasing the proportion of
women of menopausal age who have been counseled about estrogen
replacement therapy for the prevention of osteoporosis had no data
subsequent to the 1994 baseline to chart progress. Annual hip fracture
rates increased among people aged 65 years and older, and rates of
activity limitation due to chronic back conditions increased from the
1986--88 baseline.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and Prevention, National Center for Health Statistics, *Healthy
People 2000 Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Arthritis, Osteoporosis, and Chronic Back Conditions {#arthritis-osteoporosis-and-chronic-back-conditions-1 .Heading-Special-Sub}

**Goal:** Prevent illness and disability related to arthritis and other
rheumatic conditions, osteoporosis, and chronic back conditions.

  ------------------ -------------------------------------------------------------
  **Number**         **Objective Short Title**

  **Arthritis and    
  Other Rheumatic    
  Conditions**       

  2-1                Mean number of days without severe pain

  2-2                Activity limitations due to arthritis

  2-3                Personal care limitations

  2-4                Help in coping

  2-5                Employment rate

  2-6                Racial differences in total knee replacement

  2-7                Seeing a health care provider

  2-8                Arthritis education

  **Osteoporosis**   

  2-9                Cases of osteoporosis

  2-10               Hospitalization for vertebral fractures

  **Chronic Back     
  Conditions**       

  2-11               Activity limitations due to chronic back conditions
  ------------------ -------------------------------------------------------------

## Healthy People 2010 Objectives

### Arthritis and Other Rheumatic Conditions

2-1. (Developmental) Increase the mean number of days without severe
pain among adults who have chronic\
joint symptoms.

**Potential data sources:** Behavioral Risk Factor Surveillance System
(BRFSS), CDC, NCCDPHP; National Health Interview Survey (NHIS), CDC,
NCHS.

Public health researchers measure days without severe pain by asking,
"During the past 30 days, for about how many days did pain make it hard
for you to do your usual activities, such as self-care, work, or
recreation?" Pain is the most important symptom among persons with
arthritis, resulting in the widespread use of conventional prescription
and nonprescription medications, surgical interventions, and alternative
medical treatments. A measure of pain-free days provides a pertinent and
understandable performance-based approach for tracking this key
health-related quality of life (HRQOL) determinant for persons with
arthritis. Increasing days without severe pain is a feasible target,
given more widespread use of available interventions (medical,
educational, exercise, nutritional) that are likely to affect this
measure. Health surveys variously ask about chronic joint symptoms or
arthritis in addressing arthritis and other rheumatic conditions, which
is why both terms are used for these objectives.

2-2. Reduce the proportion of adults with chronic joint symptoms who
experience a limitation in activity\
due to arthritis.

**Target:** 21 percent.

**Baseline:** 27 percent of adults aged 18 years and older with chronic
joint symptoms experienced a limitation in activity due to arthritis in
1997 (age\
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older\              | **Limitation\       |
| With Chronic Joint Symptoms, 1997**            | in Activity\        |
|                                                | Due to Arthritis**  |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 27                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 27                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 18                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 16                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 32                  |
+------------------------------------------------+---------------------+
| > White                                        | 27                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 28                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 27                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 32                  |
+------------------------------------------------+---------------------+
| > White                                        | 27                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 31                  |
+------------------------------------------------+---------------------+
| > Male                                         | 22                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 36                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 30                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 24                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 years and older)  |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 34                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 32                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 26                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

2-3. Reduce the proportion of all adults with chronic joint symptoms who
have difficulty in performing two or more personal care activities,
thereby preserving independence.

**Target:** 1.4 percent.

**Baseline:** 2.0 percent of adults aged 18 years and older with chronic
joint symptoms experienced difficulty performing two or more personal
care activities in 1997 (age adjusted to the year 2000 standard
population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older\              | **Personal Care     |
| With Chronic Joint Symptoms, 1997**            | Limitations**       |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 2.0                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DSU                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 3.6                 |
+------------------------------------------------+---------------------+
| > White                                        | 1.8                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 3.5                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 1.9                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 3.4                 |
+------------------------------------------------+---------------------+
| > White                                        | 1.7                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 2.2                 |
+------------------------------------------------+---------------------+
| > Male                                         | 1.6                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 5.4                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | 2.4                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 0.9                 |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 years and older)  |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 3.4                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | 2.2                 |
+------------------------------------------------+---------------------+
| > At least some college                        | 1.4                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Arthritis and other rheumatic conditions affect quality of life in many
ways and are key items of personal interest to individuals with these
conditions.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^57]**^,^**
[^58]**^,^** [^59]**^,^** [^60]**^,^** [^61] From a public health
perspective, validated measures of HRQOL are essential for monitoring
the impact of clinical and public health interventions.

Activity limitation occurs frequently among persons with arthritis and
is an important functional element that can compromise independence.
Activity limitation affects 27 percent of all persons who have
arthritis,**^1^** making it the number one cause of activity limitations
in the United States.Error: Reference source not found The activity
limitations of arthritis also indirectly affect health and independence
by decreasing physical activity, increasing weight, and placing persons
at higher risk for all the adverse outcomes of those risk factors.

As the leading cause of disability, arthritis is a leading cause of
difficulty in performing personal care activities and thereby a leading
cause of loss of independence. Therefore, maintaining independence,
especially in personal care, is important for persons with arthritis.

2-4. (Developmental) Increase the proportion of adults aged 18 years and
older with arthritis who seek help in coping\
if they experience personal and emotional problems.

**Potential data sources:** National Health Interview Survey (NHIS),
CDC, NCHS; Behavioral Risk Factor Surveillance System (BRFSS), CDC,
NCCDPHP.

Coping difficulties, depression, anxiety, and low self-efficacy are
recognized as major personal and emotional problems among persons with
arthritis.Error: Reference source not found These problems are
especially frequent among persons who experience physical pain. Because
arthritis is a leading cause of chronic pain, monitoring these mental
health outcomes can help assess the success of applied
interventions.Error: Reference source not found

2-5. Increase the employment rate among adults with arthritis in the
working-aged population.

**Target:** 78 percent.

**Baseline:** 67 percent of adults aged 18 to 64 years with arthritis
were employed in the past week in 1997 (age adjusted to the year 2000
standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 18 to 64 Years With Arthritis,   | **Employed in\      |
| 1997**                                         | Past Week**         |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 67                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 46                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 56                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 54                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 52                  |
+------------------------------------------------+---------------------+
| > White                                        | 69                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 60                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 67                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 53                  |
+------------------------------------------------+---------------------+
| > White                                        | 70                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 60                  |
+------------------------------------------------+---------------------+
| > Male                                         | 74                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 39                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 54                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 77                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 to 64 years)      |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 47                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 65                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 78                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

Labor force participation rates (which parallel employment rates) for
all persons of working age (18 to 64 years) in 1994 were 71 percent for
females and 87 percent for males.Error: Reference source not found Rates
for persons with arthritis, however, are far below these numbers.Error:
Reference source not found A part of this low rate may be increased
through early diagnosis and appropriate management, improved
self-management, and improved job retention efforts. Raising this low
rate will help foster independence for affected persons and reduce the
demands on families and society. Reducing demands on families and
society is particularly important as demographic changes lead to fewer
workers for each nonworker.

2-6. (Developmental) Eliminate racial disparities in the rate\
of total knee replacements.

**Potential data sources:** Medicare data, HCFA; National Hospital
Discharge Survey (NHDS), CDC, NCHS; Hospital Cost and Utilization
Project (HCUP), AHRQ.

Studies have shown that African Americans have much lower rates of total
knee replacement than whites, even when adjusted for age, gender, and
insurance coverage.Error: Reference source not found The reasons for
this difference are unclear, but the effect is that many persons are not
getting needed interventions to reduce pain and disability. This is one
component of a more widespread problem of racial differences in medical
care that is difficult to explain by financial or access-to-care issues.

2-7. (Developmental) Increase the proportion of adults who have seen a
health care provider for their chronic joint symptoms.

**Potential data source:** National Health Interview Survey (NHIS) CDC,
NCHS.

Studies using the 1989 National Health Interview Survey have shown that
16 percent of adults aged 18 years and older have not seen a doctor for
their arthritis.[^62] Appropriate medical management, patient and
provider education, improved self-management, and physical
activity---all encouraged by providers---can reduce arthritis pain and
disability. Increasing the percentage of persons who seek a diagnosis
and treatment from a health care provider for their chronic joint
symptoms is an objective amenable to public awareness campaigns to
counter the myths that arthritis is part of normal aging and nothing can
be done for it. This objective is especially important for the
working-aged population, the upper age limit of which is likely to rise
as the overall population ages through the 2030s.

2-8. (Developmental) Increase the proportion of persons with arthritis
who have had effective, evidence-based arthritis education as an
integral part of the management of their condition.

**Potential data sources:** National Health Interview Survey (NHIS),
CDC, NCHS; Behavioral Risk Factor Surveillance System (BRFSS), CDC,
NCCDPHP.

Existing evidence-based education interventions, such as the Arthritis
Self-Help Course, are effective in reducing arthritis pain and reducing
physician visits for arthritis.Error: Reference source not found These
beneficial interventions, which include information about community and
self-help resources, are estimated to reach less than 1 percent of the
population with arthritis.Error: Reference source not found Expanding
the dissemination of the benefits of interventions currently available
offers the opportunity of quickly improving the health of all persons
with arthritis and reducing the impact of arthritis nationally.
Education efforts should be provided in a culturally and linguistically
competent manner.

### Osteoporosis

2-9. Reduce the proportion of adults with osteoporosis.

**Target:** 8 percent.

**Baseline:** 10 percent of adults aged 50 years and older had
osteoporosis as measured by low total femur bone mineral density (BMD)
in 1988--94 (age adjusted to the year 2000 standard population).

**Target setting method:** 20 percent improvement.

**Data source:** National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Adults Aged 50 Years and Older, 1988--94**   | **Osteoporosis\     |
|                                                | as Measured\        |
|                                                | by Low Bone Mineral |
|                                                | Density**           |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 10                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 7                   |
+------------------------------------------------+---------------------+
| > White                                        | 10                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Mexican American                             | 10                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 10                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 7                   |
+------------------------------------------------+---------------------+
| > White                                        | 10                  |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 16                  |
+------------------------------------------------+---------------------+
| > Male                                         | 3                   |
+------------------------------------------------+---------------------+
| **Education level**                            |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 11                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 11                  |
+------------------------------------------------+---------------------+
| > At least some college                        | 9                   |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

BMD has been identified as one of the primary predictive factors for
osteoporosis-related fractures.[^63]**^,^** [^64]**^,^** [^65]
Osteoporosis is defined as a BMD value that is more than 2.5 standard
deviations below that of an average young adult.[^66]

The proportion of adults aged 50 years and older with osteoporosis in
the total femur region is 10 percent (16 percent in women and 3 percent
in men). Osteoporosis occurs in nonwhite women and in men, although the
rates of disease are not as high as the rates found among white women.
These estimates are based on the total femur; estimates based on a
different skeletal site (or combination of sites) may differ. For
example, the proportion of white women with osteoporosis in Olmsted
County, Minnesota, was established to be approximately 16 to 17 percent
at the femur, lumbar spine, or wrist when each site was considered
separately. However, 30 percent of women had osteoporosis in at least
one of the three sites.[^67]

Osteoporosis is a major risk factor for hip fracture. Virtually all
persons with a hip fracture are hospitalized for treatment.Error:
Reference source not found Two-thirds of persons who fracture a hip do
not return to their prefracture level of functioning. Health care
expenditures for hip fractures in 1995 have been estimated at \$8.7
billion.Error: Reference source not found Interventions that reduce the
rate of osteoporosis should have a marked impact on the rate of hip
fractures. Estimates indicate that osteoporosis contributes to 90
percent of hip fractures in women and 80 percent of hip fractures in
men.Error: Reference source not found Increasing BMD by 5 percent may
decrease the risk of fractures by 25 percent.[^68]

Although osteoporosis increases the risk of fractures, most hip
fractures result from falls.Error: Reference source not found Some risk
factors associated with falls may be amenable to interventions. These
risk factors include impaired vision, use of long-acting psychotropic
drugs, physical inactivity, muscle weakness, and poor health.[^69]\
(See Focus Area 15. Injury and Violence Prevention.)

2-10. Reduce the proportion of adults who are hospitalized\
for vertebral fractures associated with osteoporosis.

**Target:** 14.0 hospitalizations per 10,000 adults aged 65 years and
older.

**Baseline:** 17.5 hospitalizations per 10,000 adults aged 65 years and
older were for vertebral fractures associated with osteoporosis in 1998
(age adjusted to the year 2000 standard population).

**Target setting method:** 20 percent improvement.

**Data source:** National Hospital Discharge Survey (NHDS), CDC, NCHS.

+------------------------------------------------+---------------------+
| **Adults Aged 65 Years and Older, 1998**       | **Hospitalizations  |
|                                                | for Vertebral       |
|                                                | Fractures           |
|                                                | Associated With     |
|                                                | Osteoporosis**      |
+================================================+=====================+
|                                                | Rate per 10,000     |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 17.5                |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | 14.0                |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 19.6                |
+------------------------------------------------+---------------------+
| > Male                                         | 13.9                |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Age groups (not age adjusted)                  |                     |
+------------------------------------------------+---------------------+
| > 65 to 74 years                               | 6.7                 |
+------------------------------------------------+---------------------+
| > 75 to 84 years                               | 26.0                |
+------------------------------------------------+---------------------+
| > 85 years and older                           | 39.0                |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Vertebral fractures are the most common fracture due to
osteoporosis.[^70] About 30 to 50 percent of women and 20 to 30 percent
of men will experience vertebral fractures in their lifetime.Error:
Reference source not found The overall number of cases of these
fractures rises rapidly with increasing age. Among white women, the rate
rises from 6 percent among those aged 50 to 59 years to about 75 percent
among those aged 90 years and older.[^71] Most of these fractures cause
little difficulty and go unrecognized. However, 33 percent of the
fractures will be diagnosed clinically, 8 percent will require
hospitalization,[^72] and about 2 percent will require long-term nursing
care.[^73]

The most common symptom of vertebral fractures is back pain, which is
reported in about half of the cases. People with these fractures are
more likely to have difficulty performing activities of daily living,
such as bending, reaching above the head, and walking. Changes in the
outward appearance of people experiencing these fractures is a loss of
height and the development of a humped back.Error: Reference source not
found

Interventions that reduce the number of persons with osteoporosis should
reduce the rates of vertebral fractures. Falls associated with fractures
at other sites do not play a prominent role in these fractures. Normal
daily activities can place sufficient stress on the vertebra to cause
fractures.Error: Reference source not found

For discussion of calcium and vitamin D, see Focus Area 19. Nutrition
and Overweight.

### Chronic Back Conditions

2-11. Reduce activity limitation due to chronic back conditions.

**Target:** 25 adults per 1,000 population aged 18 years and older.

**Baseline:** 32 adults per 1,000 population aged 18 years and older
experienced activity limitation due to chronic back conditions in 1997
(age adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 18 Years and Older, 1997**       | **Activity          |
|                                                | Limitation Due to   |
|                                                | Chronic Back        |
|                                                | Conditions**        |
+================================================+=====================+
|                                                | Rate per 1,000      |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 32                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 68                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 18                  |
+------------------------------------------------+---------------------+
| > Asian                                        | 15                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 36                  |
+------------------------------------------------+---------------------+
| > White                                        | 31                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 28                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 32                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 36                  |
+------------------------------------------------+---------------------+
| > White                                        | 32                  |
+------------------------------------------------+---------------------+
| ###### Gender                                  |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 32                  |
+------------------------------------------------+---------------------+
| > Male                                         | 31                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | 77                  |
+------------------------------------------------+---------------------+
| > Near poor                                    | 53                  |
+------------------------------------------------+---------------------+
| > Middle/high income                           | 24                  |
+------------------------------------------------+---------------------+
| **Education level** (aged 25 years and older)  |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | 54                  |
+------------------------------------------------+---------------------+
| > High school graduate                         | 35                  |
+------------------------------------------------+---------------------+
| > Some college                                 | 28                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

Persons who are overweight and persons who frequently bend over or lift
heavy objects are at risk for low back injuries.[^74] Occupations that
require repetitive lifting, particularly in a forward bent and twisted
position, place employees at especially high risk. Other risk factors
for low back injury include exposure to vibration produced by vehicles
or industrial machinery, prolonged vehicle driving, and certain sports
activities.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,^**
[^75]**^,^** [^76] Predictors of back problems may include diminished
lumbar flexibility, trunk muscle strength, and hamstring
elasticity.[^77] Osteoporosis increases the risk of vertebral
compression, which may account for the increase in reported low back
pain in older females.[^78]**^,^** [^79] Increased age also is
associated with back pain.[^80] In addition, persons who have
experienced back problems in the past are at increased risk for future
injury.Error: Reference source not found**^,^** [^81]

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-3. Counseling about health behaviors

3\. Cancer

3-10. Provider counseling about cancer prevention

6\. Disability and Secondary Conditions

6-4. Social participation among adults with disabilities

6-5. Sufficient emotional support among adults with disabilities

6-8. Employment parity

7\. Educational and Community-Based Programs

7-5. Worksite health promotion programs

7-6. Participation in employer-sponsored health promotion activities

7-10. Community health promotion programs

7-12. Older adult participation in community health promotion activities

15\. Injury and Violence Prevention

15-28. Hip fractures

19\. Nutrition and Overweight

19-1. Healthy weight in adults

19-2. Obesity in adults

19-11. Calcium intake

19-16. Worksite promotion of nutrition education and weight management

19-17. Nutrition counseling for medical conditions

20\. Occupational Safety and Health

20-2. Work-related injuries

20-3. Overexertion or repetitive motion

22\. Physical Activity and Fitness

22-1. No leisure-time physical activity

22-2. Moderate physical activity

22-3. Vigorous physical activity

22-4. Muscular strength and endurance

22-5. Flexibility

22-8. Physical education requirement in schools

22-10. Physical activity in physical education class

27\. Tobacco Use

27-1. Adult tobacco use

27-5. Smoking cessation by adults

27-7. Smoking cessation by adolescents

27-17. Adolescent disapproval of smoking

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Activity limitations:** Problems in a person's performance of everyday
functions such as communication, self-care, mobility, learning, and
behavior.

**Arthritis:** Shorthand for arthritis and other rheumatic conditions.

**Arthritis and other rheumatic conditions:** More than 100 conditions
(or diseases or problems) that primarily affect the joints, muscles,
fascia, tendons, bursa, ligaments, and other connective tissues of the
body.

**Bone mineral density (BMD):** Measurement used to determine the
presence of osteoporosis.

**Chronic back conditions:** Low back pain and other conditions
affecting only the back.

**Chronic joint symptoms:** Pain, aching, stiffness, or swelling in or
around a joint that was present on most days for at least 1 month in the
past 12 months.

**Disability:** General term used to represent the interactions between
individuals with a health condition and barriers in their environment.
The term disability is operationalized as self-reported activity
limitations or use of assistive devices or equipment related to an
activity limitation.

**Musculoskeletal conditions:** Problems that affect the skeleton,
joints, muscles, and connective tissues of the body.

**Osteoarthritis:** A slowly progressive, degenerative joint disease
that results from the breakdown of cartilage and leads to pain and
stiffness; usually affects the knees, hips, and hands; the most common
form of arthritis.

**Osteopenia:** A condition similar to osteoporosis (see below) except
the reduction in bone mass is not as severe.

**Osteoporosis:** Bone disease characterized by a reduction of bone mass
and a deterioration of the microarchitecture of the bone leading to bone
fragility.

**Personal care activities:** Eating, bathing, dressing, or getting
around inside the home, including getting in or out of bed or chairs and
using the toilet (including getting to the toilet).

**Rheumatoid arthritis:** A chronic, inflammatory disease of the body
that produces its most prominent manifestations in joints, often leading
to joint pain, stiffness, and deformity.

**Work disability:** Limited in the amount or kind of work; unable to
work.

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