Testimony

Statement by
Joe Sniezek, M.D., M.P.H.
Director
Arthritis Program
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
on
CDC's Role in Combating the Burden of Arthritis
before the
Subcommittee on Aging
Committee on Health, Education, Labor, and Pensions
U.S. Senate

June 8, 2004

Thank you, Mr. Chairman, Members of the Committee, for the opportunity to address an important health problem in our society - that of preventing, controlling and curing arthritis.

The National Arthritis Act of 1974 (Public Law 93-640) as enacted in 1975 has largely been successful in promoting basic and clinical arthritis research and establishing Multidisciplinary Clinical Research Centers. Arthritis is a large problem that is getting larger as our population ages. The public health efforts called for in the 1974 Act have only recently been initiated. The National Arthritis Action Plan: A Public Health Strategy was published in 1999. Our health priorities for the nation, Healthy People 2010, include arthritis objectives for the very first time.

In my remarks today, I would like to focus on the impact of arthritis in the United States and the opportunities public health has to make a difference in reducing the pain and the disability associated with arthritis. I would also like to highlight a few of our activities: an example from one of our state-funded arthritis programs; a research program examining the incidence and progression of arthritis; and, a health communications campaign designed to increase physical activity among persons with arthritis.

Impact of Arthritis: Today and in the Future

Arthritis comprises over 100 different diseases and conditions. The most common are osteoarthritis, gout, fibromyalgia, and rheumatoid arthritis. Common symptoms of arthritis include pain, aching, stiffness and swelling. Some forms of arthritis, such as rheumatoid arthritis and lupus, affect multiple organs, and associated with premature death.

In 2001, 49 million adults reported a doctor had told them they had arthritis; nearly one of every four adults--making it among the most common health problems in the United States. An additional 21 million Americans reported chronic joint symptoms that may be arthritis, but have yet to be told by a physician they have arthritis. In the next 25 years as the population ages, CDC estimates that 71 million adults will have arthritis, including a doubling of the rate among adults over age 65. This is likely a conservative number, since it does not take into account the ongoing obesity epidemic in America, which may significantly contribute to the future prevalence of arthritis.

Although rarely discussed, arthritis causes over nine thousand deaths each year. Most notable, is the fact that arthritis-related mortality disproportionately affects women and minorities. For example, systemic lupus deaths show marked age, sex, and race-specific disparities with the highest death rates occurring among working-age, black women.

Arthritis and its related disability cause an enormous burden for the people who have arthritis, their families and society. Arthritis is the most frequent cause of activity limitation in America; more than eight million citizens are limited in some way because of arthritis. Arthritis is also a significant cause of work disability, especially for persons with inflammatory arthritis, such as rheumatoid arthritis, of which, as many as 30 percent may be work disabled. Each year, 750,000 hospitalizations and 36 million outpatient medical care visits occur because of arthritis. Arthritis is costly to society and individuals. In 1997, arthritis cost more than $51 billion in direct medical costs and another $35 billion in indirect costs. No doubt, these numbers will increase dramatically as our population ages and the number of people with arthritis increases.

We know other things about people with arthritis. People with arthritis

  • Are older, more often female, and have a much poorer quality of life.
  • Are more likely to be overweight or obese, which is associated with further progression of disease and, given the obesity epidemic, means even more people affected in the future.
  • Are less physically active, which is associated with higher medical costs.
  • Often don't discuss their joint symptoms with their doctors, resulting in delayed diagnosis and greater progression of disease. 21 million Americans report joint pain but have not been told they have arthritis.
  • Are not receiving existing interventions, such as counseling to increase physical activity, achieving a healthy weight, and learning about self-management.

The Role of Public Health in Arthritis

CDC has identified the following critical priorities to address arthritis:

  • Increase early diagnosis and appropriate medical management of arthritis
    Although there is no cure for most types of arthritis, early diagnosis and appropriate management is important, especially for inflammatory types of arthritis. Early targeted therapy for rheumatoid arthritis had been shown to decrease joint destruction and improve outcomes.

  • Promote healthy lifestyles
    Medical treatment alone, however, is not sufficient. Public health activities that reach broad population groups with arthritis are needed. Our challenge is to both identify and implement effective strategies to improve the health of entire population segments. Only since 1990, have the benefits of physical activity among people with arthritis been appreciated. Prior to 1990, people with arthritis were told by their physicians to rest their joints. Evidence now exists that shows physical activity is beneficial for most types of arthritis, can improve health AND function, and improve symptoms.

  • Increase the use of disease self management strategies
    Programs that teach people with arthritis to better manage their disease and optimize function can reduce both pain and health care costs. There is a very robust science base that demonstrates the positive impacts of participation in the Arthritis Self Help Course-participants report a 20 percent decrease in pain, and a 40 percent decrease in physician visits, even four years after course participation. A companion course, the Chronic Disease Self Management Program, has also been developed and has demonstrated positive impacts among people with a variety of chronic conditions including arthritis, heart disease, lung disease and diabetes. Less than one percent of Americans with arthritis who could benefit participate in such programs. Programs are not readily available in all areas.

Reducing arthritis-related disability will benefit our aging population in America. In seven years, the leading edge of the baby-boomers will reach age 65. Many older Americans, those most likely to have arthritis and to be limited by arthritis, may need to or wish to work longer. We will need to better understand how we can reduce arthritis-related disability and how older Americans can be accommodated in the workplace so that they can remain active and, if they choose to be, employed. This aging trend will have enormous implications for our society.

CDC and the public health community in our states and communities have a continued role to play in bringing the benefits of prevention to persons with arthritis. Public health brings the focus on population-based approaches to health, the knowledge of what works, and links to the clinical community. What CDC brings to the table is its well-recognized scientific expertise, long-standing experience in prevention research, the ability to evaluate health promotion programs and identify those that work, knowledge of the public health network and the ability to work with states and communities to implement disease prevention and health promotion programs, and unique surveillance capacity to better guide programmatic efforts.

Priority areas to address:

  • Awareness. Market research conducted by the Arthritis Foundation showed that many people are not aware of the available programs that improve the quality of life for people with arthritis.

  • Availability. There are simply not enough programs available and we need to expand the toolbox of programs.

  • Accessibility. In addition to expanding the number and type of existing interventions available, we need to discover how best to reach people with arthritis.

CDC works closely with the Arthritis Foundation, the voice for people with arthritis and their families for more than 50 years. The Arthritis Foundation recognizes the need for health promotion strategies for people with arthritis that are tested and proven effective. CDC's strength is its ability to demonstrate the effectiveness of an intervention strategy or program and help states and communities put it into practice.

The growing evidence for the benefits of healthy behaviors (physical activity and weight control) and disease management strategies for people with arthritis must be shared and implemented widely in public health practice. CDC can, through its leadership role in the public health community, make sure that the growing body of evidence that we can improve the quality of life among people with arthritis is applied through public health practice and supported by clinical medical practice.

Current CDC Efforts

Despite the enormous burden of arthritis, public health efforts for arthritis are fairly new. Prior to 1998, we are aware of only two states that had organized activities addressing arthritis: Missouri and Ohio. There was no national public health plan for arthritis and arthritis had never been made a priority in our national health objectives. CDC, too, had limited efforts.

The National Arthritis Action Plan: A Public Health Strategy was developed by CDC, the Association of State and Territorial Health Officials, and the Arthritis Foundation with the help and input of 90 other organizations to address this large and growing problem. This landmark plan recommends national, coordinated efforts to reduce pain and disability and improve the quality of life for people with arthritis. This plan forms the foundation for CDC's arthritis efforts.

The primary goal of the CDC Arthritis Program is to improve the quality of life for people affected by arthritis-decreasing the pain and disability that often accompany arthritis. Since 1999 when CDC received its first ever appropriation for arthritis, CDC has made progress.

  • Support to States
    A core activity of the CDC Arthritis Program has been to fund state health departments to develop activities to address the burden of arthritis in their state. CDC currently funds Arthritis Programs in 36 state health departments. At present, 35 states have active coalitions which guide activities and share responsibility for reducing the burden of arthritis, and 31 states have published plans for reducing the burden of arthritis in their state. Partnerships and joint activities with the Arthritis Foundation are key features of these state programs. Prior to 1999, only ten states had gathered data to measure the number of people with arthritis in their state; in 2001, all 50 states and the District of Columbia measured how many people with arthritis live in their state. Illinois is an example of CDC's state based arthritis programs.

      Illinois: Reaching Rural and Underserved Populations: Promoting Physical Activity Interventions for People with Arthritis

      In Illinois, 2.1 million adults had doctor-diagnosed arthritis and an additional 940,000 reported chronic joint symptoms in 2001. In Illinois, the prevalence of arthritis in rural areas is 33 percent, higher than the prevalence in Chicago (24 percent) other Illinois urban areas (29 percent).

      With CDC support, Illinois is increasing its efforts to reduce the burden of arthritis by increasing the availability of evidence-based arthritis physical activity programs in five counties, representing rural and underserved populations. In partnership with county health departments, the Arthritis Foundation's PACE® (People with Arthritis Can Exercise), Aquatics and Arthritis Self-Help Course programs are being offered, reaching over 700 new participants. The coordinators responsible for these projects at the county level report that interest in and demand for the programs has exceeded expectations. In fact, coordinators are recruiting more course leaders and looking for additional venues to offer programs to meet this demand. Working through local health departments may be an efficient way to provide evidenced-based programs to people with arthritis in rural and underserved areas.

      Implications and Impact

      Arthritis-specific interventions have been proven to reduce the impact of arthritis or chronic joint symptoms by improving function and reducing pain and the need for physician visits. These interventions, however, are scarce in rural and underserved areas where people at risk of arthritis-related disability reside. This Illinois strategy to expand these community-based programs can serve as a model to help other states increase the availability of similar programs in rural and underserved areas.

    We will continue to work with states, as many have limited resources--only enough to conduct modest demonstration projects. States will be challenged to ensure that self management education and physical activity programs for arthritis are available statewide.

  • Improve the science base.

    • CDC has provided long-term support to the Johnston County (NC) Osteoarthritis Project, a unique, population-based, longitudinal study of hip and knee osteoarthritis among ~3200 rural white and black residents aged 45 and older. Hip and knee osteoarthritis are two of the most common, disabling, and expensive types of arthritis.

      • The Project has already shown a higher rate of hip and knee osteoarthritis among blacks than previously thought, the importance of overweight in the development of osteoarthritis among blacks, and the importance of pain in determining the functional limitations that occur.

      • Expected findings will better characterize the impact of osteoarthritis on previously understudied groups (e.g., blacks, rural residents) and suggest the high risk groups among them for targeted interventions.

      • Additional studies will find factors linked to the initial occurrence as well as subsequent progression of osteoarthritis, which will allow us to determine: 1) which biomarkers (e.g., blood tests, genes) can be used to make an earlier diagnosis and to suggest who needs more aggressive treatment, 2) how single and combinations of factors (e.g., joint injury, obesity, age, body composition, osteoarthritis in other joints) put a person at higher risk, and 3) how a person can modify these factors to reduce their impact.

    • CDC co-sponsored "Stepping Away from OA: Prevention of Onset, Progression, and Disability of Osteoarthritis." This NIH led effort addressed the preventive aspects of this most common type of arthritis.

    • CDC co-sponsored a 2003 international conference summarizing the evidence for exercise and physical activity as underused interventions to prevent arthritis disability. This conference also made recommendations about what needs to be done next for biomedical and population-based research.

  • Identify and evaluate promising interventions
    Public health goals for arthritis include increasing the use of effective self-management strategies to minimize pain and optimize function among people with arthritis. Central to achieving this goal is identifying and evaluating promising interventions-those interventions that have demonstrated some potential to improve the quality of life for people with arthritis. We are working to develop sufficient scientific evidence so we can confidently tell Americans with arthritis 'if you participate in this activity, you can receive this benefit'.

    • CDC is also funding the evaluation of several public health interventions designed to increase physical activity among people with arthritis.

      The PACE (People with Arthritis CAN Exercise) program, developed and disseminated by the Arthritis Foundation specifically for people with arthritis, is currently being evaluated at the Universities of Missouri and North Carolina. This program teaches program participants exercises which can reduce their pain and improve there ability to move; pilot results are promising.

      Active Living Every Day, a program developed by the Cooper Clinic, is a program that has been demonstrated to help people increase their physical activity by specifically attending to barriers that get in their way. Past evaluations have shown that participants have improved cardio-respiratory fitness and reduce blood pressure and body fat percentage. These evaluations have not addressed people with arthritis. The University of North Carolina is evaluating the Active Living Every Day program among people with arthritis.

  • Increasing awareness - reaching the public.
    CDC and its partners are also reaching Americans with arthritis through mass media-specifically radio, newspapers, and displays at their local stores.

    • CDC has developed a marketing campaign to promote physical activity among people with arthritis. The campaign was designed with an arthritis-specific message, to reflect a major motivator for people with arthritis. Audience research demonstrated that what people with arthritis are most seeking is pain relief, though most do not want to depend on medications for their pain relief. This research led to the development of the marketing campaign: Physical Activity. The Arthritis Pain Reliever. This campaign was quite successful in pilot testing: 50 percent reported hearing or seeing the message and 20 percent reported increasing their physical activity in response to something they heard or read. This campaign is currently being used by 35 of the 36 state health departments who receive arthritis funding from CDC.

        Oregon: Using the media to reach people with arthritis: Physical Activity. The Arthritis Pain Reliever.

        Public Health Problem

        In Oregon, 567,000 adults had doctor-diagnosed arthritis and an additional 365,000 reported chronic joint symptoms in 2001.

        Program Example

        With CDC support, the Oregon Department of Human Services, Arthritis Program, pilot tested the CDC-developed health communications campaign, Physical Activity. The Arthritis Pain Reliever, in Bend, Oregon (Population 52,000). The campaign used a combination of radio, print and television media to reach the target population. Arthritis prevalence is estimated to be 39 percent in this area.

        Implications and Impact

        The campaign reached its target audience. In a post campaign survey of 300 adults with arthritis

        • 56 percent reported hearing a message about the health benefits of physical activity for arthritis;
        • Of those who heard the message, 24 percent recalled the campaign theme, "Physical activity. The arthritis pain reliever." and 71 percent recalled "Physical activity is good for arthritis;"
        • 14 percent of people in the campaign target group (ages 45 to 64, lower SES, white and African American) reported increasing their physical activity in response to something they read or heard.

        The CDC-developed campaign performed well in the Oregon implementation in both reaching the target audience and producing significant changes in reported health behavior. Most CDC-funded state arthritis programs are planning to implement Physical Activity. The Arthritis Pain Reliever. The Oregon implementation experience serves as a model for other states.

  • Improve how we measure the burden of arthritis.

    • Consistent with recommendations in the National Arthritis Action Plan, CDC has improved methods used to monitor the burden and cost of arthritis in general, and as described above has established its impact on mortality, hospitalization, ambulatory care visits, and disability. We plan to do the same for specific types of arthritis, such as osteoarthritis, rheumatoid arthritis, and systemic lupus erythematosus, and for children as well, where arthritis impact is poorly understood. Standard data sources don't help much for rare diseases like systemic lupus erythematosus, so CDC is supporting the development of special registries in Michigan and Georgia to best determine the impact.

In conclusion, I would like to thank the Committee for its leadership and commitment to the health of our nation and the interest in people affected by arthritis. Great progress has been made in addressing arthritis, one of our most common chronic conditions. The nation has a national plan, catalyzing activities in both the public and private sectors. State programs, almost unheard of just six years ago exist in 36 states. The pain and disability of arthritis can be improved. We need to continue our work to identify promising approaches, develop new approaches, and put this science into action-getting programs that work out to the people who need them.

I would be happy to answer any questions from the Committee.

References

1a. Arthritis Foundation, Association of State and Territorial Health Officials, CDC. National Arthritis Action Plan: A Public Health Strategy. Atlanta, Georgia: Arthritis Foundation, 1999.

1b. HP2010 Health Objectives for the Nation.
1c. Arthritis Foundation, Primer on the Rheumatic Diseases, 2001. 12th Edition, John H. Klippel, Editor. Arthritis Foundation; Atlanta, GA.

2. Bolen J, Helmick CG, Sacks J, Langmaid G. Prevalence of self-reported arthritis or chronic joint symptoms among adults - United States, 2001, MMWR, 2002; 51(42):948-50.

3. Hootman JM, Helmick CG, Langmaid G. Public Health and Aging: Projected Prevalence of Self-Reported Arthritis or Chronic Joint Symptoms Among Persons Aged >65 Years --- United States, 2005-2030. MMWR, 2003; 52(21):489-91.

4. Sacks JJ, Helmick CG, Langmaid G. Deaths from Arthritis and Other Rheumatic Conditions, United States, 1979 - 1998. In Press: J Rheumatol, 2004.

5. Sacks JJ, Helmick CG, Langmaid G, Sniezek JE. Trends in Deaths from Systemic Lupus Erythematosus --- United States, 1979-1998. MMWR, 2002; 51(17):371-4.

6. Centers for Disease Control and Prevention. Prevalence of Arthritis --- United States, 1997. MMWR, 2001; 50(17):334-6.

7. Sokka, T. Work disability in early rheumatoid arthritis. Clin Exp Rheumatol, 2003; 21(5 suppl):S71-4.

8. Lethbridge-Cejku M, Helmick CG, Popovic JR. Hospitalizations for arthritis and other rheumatic conditions: data from the 1997 National Hospital Discharge Survey. Med Care, 2003; 41(12):1367-73.

9. Hootman JM, Helmick CG, Schappert SM. Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997. Arthritis Care Res, 2002; 47(6):571-81.

10. Murphy L, Cisternas M, Yelin E, et al. Update: Direct and Indirect Costs of Arthritis and Other Rheumatic Conditions --- United States, 1997. MMWR, 2004; 53(18):388-9.

11. Mili FD, Helmick CG, Zack MM, Moriarty D. Health-related quality of life among adults reporting arthritis: Behavioral Risk Factor Surveillance System, 15 states and Puerto Rico, 1996-1999. Journal of Rheumatology 2003; 30:160-6.

12. Mehrotra C, Naimi T, Seruda M, Bolen J, Pearson K. Arthritis, body mass index, and professional advice to lose weight: Implications for clinical medicine and public health. In press: Am J Prev Med.

13. Hootman JM, Macera CA, Ham S, Helmick CG, Sniezek JE. Physical activity levels among the general US adult population and in adults with and without arthritis. Arthritis and Rheumatism (Arthritis Care and Research) 2003; 49(1):129-135.

13a. Fontaine K, Heo M, Bathon J. Are U.S. adults with arthritis meeting public health recommendation for physical activity? Arthritis and Rheumatism 2004;50(2):624-28.

14. Wang G, Helmick CG, Macera A, Zhang P, Pratt M. Inactivity-associated medical costs among U.S. adults with arthritis. Arthritis Care and Research 2001;45:439-445.

15. RAO JK, CALLAHAN LF, HELMICK CG. Characteristics of persons with self-reported arthritis and other rheumatic conditions who do not see a doctor. J Rheumatol 1997;24:169-73.

16. Bolen JC, Helmick CG, Sacks JJ, Langmaid G. Adults who have never seen a health-care provider for chronic joint symptoms --- United States, 2001. Morbidity and Mortality Weekly Report 2003;52:416-419.

17. Boutaugh ML. Arthritis Foundation community-based physical activity programs: effectiveness and implementation Issues. Arthritis & Rheumatism (Arthritis Care & Research) 49(3): 463-470, 2003

18. Breedveld F, Kalden J. Appropriate and effective management of rheumatoid arthritis. Ann Rheum Dis 2004;63:627-633.

19. Minor M. 2002 Exercise and Physical Activity Conference, St. Louis, Missouri: Exercise and Arthritis "We know a little bit about a lot of things…" Arthritis and Rheumatism (Arthritis Care and Research) 2003;49(1):1-2.

20. American College of Rheumatology/Association of Rheumatology Health Professionals. Proceedings from the International Conference on Health Promotion and Disability Prevention for Individuals and Populations with Rheumatic Disease: The evidence for Exercise and Physical Activity. 2003. Atlanta, Georgia.

21. Lorig K, Mazonson P, Holman HR: Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis and Rheumatism, 36(4):439-446, 1993.

22. Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW, Bandura A, Gonzales VM, Laurent DD, Holman HR . Chronic Disease self-management program-2-year health status and health care utilization outcomes. Medical Care 39(11): 1217-1223, 2001.

23. ORC Macro. Market Research for the Arthritis Foundation. A focus group study. May 2003.

24. Toal S. Assessment of Arthritis Program Capacity . Unpublished report prepared for the Arthritis Council, Chronic Disease Directors, March 2004.

25. JORDAN JM, RENNER JB, LUTA G, DRAGOMIR A, FRYER JG, HELMICK CG, HOCHBERG MC. Hip osteoarthritis (OA) is not rare in African -Americans and is different than in Caucasians. Arthritis Rheum 1997;40(9)suppl: S236 (#1232).

26. JORDAN JM, LUTA G, RENNER JB, DRAGOMIR A, FRYER JG,HELMICK CG, HOCHBERG MC. African-Americans face an increased risk of bilateral knee osteoarthritis (OA) from obesity. Arthritis Rheum 1997;40(9)suppl:S331 (#1796).

27. Jordan JM, Luta G, Renner JB, Linder GF, Dragomir A, Helmick CG, Fryer JG. Self-reported functional status in osteoarthritis of the knee in a rural, Southern community: the role of sociodemographic factors, obesity, and knee pain. Arthritis Care Res 1996; 9:273-278.

28. Jordan JM, Luta G, Renner JB, Dragomir A, Hochberg MC, Fryer JG. Knee pain and knee osteoarthritis severity in self-reported task-specific disability: the Johnston County Osteoarthritis Project. J Rheumatol 1997 ; 24:1344-1349.

29. Felson DT, Lawrence R, Dieppe PA, Hirsch R, Helmick CG, Jordan JM et al. Osteoarthritis: new insights. Ann Intern Med 2000; 133:635-646.

30. Dunn AL, Marcus BH, Kampert JB, et al. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: A randomized controlled trial. JAMA, 1999;281(4):321-34.)

31. Geppert J. Physical Activity. The Arthritis Pain Reliever. Pilot test results-unpublished report. 2003.

Last Revised: June 8, 2004