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Published 10/1/2015
Laura M. Bruse Gehrig, MD, CCD; Mary I. O’Connor, MD

Breaking the Vicious Cycle

Osteoarthritis, obesity, and musculoskeletal health disparities

Laura M. Bruse Gehrig, MD, CCD, and Mary I. O’Connor, MD

With the epidemic rise of obesity and changing demographics of the population, the critical linkage of osteoarthritis (OA), obesity, and musculoskeletal health disparities has never been of greater importance to orthopaedic surgeons.

By 2034, non-Hispanic Caucasians will no longer comprise the majority of the U.S. population. As orthopaedic surgeons, we will see this increased diversity in our patients. Treatment outcomes will be affected by disproportionate disease burdens and comorbidities among these differing racial and ethnic groups. The current state and future challenges of caring for a diverse population can no longer be ignored. Understanding musculoskeletal health disparities is the crucial first step in creating solutions for tomorrow.

The vicious cycle
Joint pain from musculoskeletal conditions often limits an individual’s ability to function at work or in the home, resulting in limited mobility, decreased physical activity, and weight gain. So begins the “vicious cycle” in which weight gain leads to greater joint pressure, increased joint pain, and the development of OA (
Fig. 1). With obesity, inactivity increases and is followed by the development of heart disease, diabetes, and depression. Thus, when such patients seek relief of joint pain, they are at higher risk of surgical complications.

The impact of obesity
The impact of obesity in the vicious cycle cannot be understated. Knee OA occurs nearly five times more frequently in individuals who are overweight than in those with a healthy body weight. This correlation is particularly concerning because more than one-third (35.7 percent) of U.S. adults age 20 years or older are obese and 69.0 percent are either overweight or obese.

The CDC reports the highest age-adjusted rates of obesity in African Americans (47.8 percent), followed by Hispanics and Latinos (42.5 percent), and Caucasians (32.6 percent). Among females, 56.6 percent of African American women, 41.4 percent of Hispanic women, and 32.8 percent of Caucasian women are obese. These are staggering statistics.

A disabled workforce
In the United States, the numbers of disabled and physically limited adults are increasing and having an impact on orthopaedic surgeons, employers, and society at large. In 2012, more than 34.5 million adults (age 18 years and older) reported having difficulty performing routine activities. Activity limitation is highest among African Americans (44.6 percent), followed by Hispanics and Latinos (43.2 percent) and Caucasians (36.2 percent).

Work limitations and severe pain were also significantly higher among Hispanics and Latinos, and African Americans compared to non-Hispanic Caucasians. These data on activity limitations correlate with the rate of arthritis at 23.1 percent in Caucasians, 38.3 percent in African Americans, and 36.4 percent in Hispanics and Latinos.

Life-threatening comorbidities
Racial and ethnic minority women not only have the highest rates of OA and obesity, but they also experience higher rates of life-threatening related illnesses such as diabetes, heart disease, and depression than their Caucasian counterparts. Compared to Caucasian women, African American and Hispanic women are 60 percent more likely to have diabetes, have rates of heart disease twice as high, and are nearly 50 percent more likely to experience depression. These disparities lead to a sequence of reciprocal cause and effect, as the experience of one illness aggravates others. Minority women, in particular, find themselves trapped in this “vicious cycle.”

Breaking the cycle
The vicious cycle is difficult to interrupt. Recognizing that women, African Americans, and Hispanics and Latinos are much more likely to be affected is critical to making positive change. Individuals, communities, policy makers, and healthcare providers all must be engaged. For the last 5 years, the Movement Is Life (MIL) group has focused on finding ways to break this vicious cycle.

MIL is a multidisciplinary coalition of orthopaedic surgeons, primary care physicians, nurses, physical therapists, community and religious leaders, and policy makers. MIL’s mission is to dramatically decrease racial and ethnic disparities in musculoskeletal health by promoting mobility to improve the quality of life of all women, as well as African American, Latino, and Hispanic individuals.

The strategic objectives developed by MIL aim to decrease disparities at the patient, provider, community, and policy level. Disparities are both patient- and provider-influenced, can be conscious or unconscious, and are real. Even when disease severity, socioeconomic status, education, and access are controlled, racial and ethnic minorities receive a lower quality of care and have worse clinical outcomes.

The economic impact of musculoskeletal disparities will be presented by MIL at this month’s US News and World Report leadership forum, “Hospital of Tomorrow.” Understanding the financial cost to society, employers, and individuals and the impact on an individual’s quality of life such disparities can have is an important step to further engagement of multiple stakeholders. In November, the sixth annual MIL Caucus will be held in Washington, D.C., highlighting past and ongoing activities of the Caucus. A follow-up article in AAOS Now will share highlights of these events.

The orthopaedist’s role
We, as AAOS members, can—and must—be part of the solution. We can increase our awareness of musculoskeletal healthcare disparities by viewing the documentary, Start Moving Start Living (
http://startmovingstartliving.com). We can share the documentary with colleagues and patients.

We must talk with our patients about the importance of movement and have the difficult conversation with them about obesity. We can influence patients to lose weight. We can explain the link between obesity, movement, and comorbidities to them. Finally, we can each ask ourselves if we are providing the same high quality care to all our patients, or whether the unconscious bias that each of us has could be affecting our treatment recommendations. Our patients will be grateful for our increased awareness and be more engaged.

Laura M. Bruse Gehrig, MD, CCD, chairs the AAOS Women’s Health Issues Advisory Board. Mary I. O’Connor, MD, is the director of the Center for Musculoskeletal Care at Yale School of Medicine and Yale-New Haven Hospital and chair of the Movement is Life Caucus; she also chairs the AAOS Diversity Advisory Board.


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