Katherine Froehlich-Grobe

Disparities in Obesity and Related Conditions Among Americans with Disabilities

BACKGROUND Despite representing nearly 20% of the U.S. population, individuals with disabilities are invisible in obesity surveillance and intervention efforts. PURPOSE The current study (1) compares obesity and extreme obesity prevalence between Americans with and without disabilities and (2) examines the association between BMI category and weight-related chronic disease risk factors in both groups. METHODS In 2012, six waves of data from the National Health and Nutrition Examination Survey (NHANES, 1999-2010) were pooled to compare the prevalence of obesity and extreme obesity between adults (aged ≥20 years, N=31,990) with disabilities (n=11,556) versus without disabilities (n= 20,434). Chronic disease risk factors (blood pressure, lipids, C-reactive protein [CRP], glucose) were compared across weight categories, by disability severity, and disability status. RESULTS Obesity (41.6%) and extreme obesity (9.3%) prevalence among those with disabilities were significantly higher than they were among those without disabilities (29.2% and 3.9%, respectively). Disability severity and disability status negatively affected nearly all chronic disease risk factors. Additionally, there was a disability-by-weight interaction: people with disabilities at all weight categories were significantly more likely to report being told they had hypertension, high cholesterol, or diabetes and to have been prescribed antihypertensive and lipid-lowering medications. CONCLUSIONS The prevalence of obesity (41.6%) and extreme obesity (9.3%) found in individuals with disabilities is high. When compared to obese adults without disabilities, obese adults with disabilities are more likely to have diabetes, high cholesterol, hypertension, and higher CRP. Thus, the study provides convincing evidence of obesity-related health disparities between Americans with and without disabilities.

Exercise for Everyone: A randomized controlled trial of Project Workout On Wheels in promoting exercise among wheelchair users

OBJECTIVE To compare the effectiveness of 2 home-based behavioral interventions for wheelchair users to promote exercise adoption and maintenance over 12 months. DESIGN Randomized controlled trial, with participants stratified into groups based on disability type (stable, episodic, progressive) and support partner availability. SETTING Exercise occurred in participant-preferred locations (eg, home, recreation center), with physiological data collected at a university-based exercise laboratory. PARTICIPANTS Inactive wheelchair users (N=128; 64 women) with sufficient upper arm mobility for arm-based exercise were enrolled. Participants on average were 45 years of age and lived with their impairment for 22 years, with spinal cord injury (46.1%) most commonly reported as causing mobility impairment. INTERVENTIONS Both groups received home-based exercise interventions. The staff-supported group (n=69) received intensive exercise support, while the self-guided group (n=59) received minimal support. Both received exercise information, resistance bands, instructions to self-monitor exercise, regularly scheduled phone calls, and handwritten cards. MAIN OUTCOME MEASURES The primary outcome derived from weekly self-reported exercise. Secondary outcomes included physical fitness (aerobic/muscular) and predictors of exercise participation. RESULTS The staff-supported group reported significantly greater exercise (∼17min/wk) than the self-guided group over the year (t=10.6, P=.00), with no significant between-group difference in aerobic capacity (t=.76, P=.45) and strength (t=1.5, P=.14). CONCLUSIONS Although the staff-supported group reported only moderately more exercise, the difference is potentially clinically significant because they also exercised more frequently. The staff-supported approach holds promise for encouraging exercise among wheelchair users, yet additional support may be necessary to achieve more exercise to meet national recommendations.

Measuring Height without a Stadiometer: Empirical Investigation of Four Height Estimates Among Wheelchair Users

Objective: This study aimed to compare four methods of measuring or estimating height among wheelchair users, to determine whether these methods result in significantly different estimates, and to determine which method is most accurate. Design: Height data were obtained for 141 wheelchair users. Height estimates included asking for self‐report and measuring recumbent length, knee height, and armspan. All analyses were conducted separately for men and women. A two‐group confirmatory factor analysis assessed which measure provided the best estimate of height in this population. It also tested the measurement invariance of the four height estimates between men and women and whether there were significant differences across these estimates within each sex. Results: Confirmatory factor analysis findings indicated that the four measures yielded significantly different height estimates and body mass index values for both men and women. For both sexes, armspan resulted in the longest estimate, and measured recumbent length resulted in the shortest, with the reverse pattern for body mass index values. The common variance estimates were outstanding for recumbent length (92%) and knee height (>83%) and were very good for self‐report (>75%), whereas the common variance for armspan was poor (<42%). Conclusions: The measurement method used to estimate height yields significantly different values for both height and body mass index among wheelchair users who cannot stand to be measured using a stadiometer. Recumbent length yields the most accurate height estimate for wheelchair users. However, when logistical and practical considerations pose difficulties for obtaining this measure, height estimates based on knee height and self‐report may provide reasonable alternatives.

An exercise trial for wheelchair users: Project workout on wheels

There is growing interest in promoting health for people with disabilities, yet evidence regarding community-based interventions is sparse. This paper describes the design details of a randomized controlled trial (RCT) that will test the effectiveness of a multi-component behaviorally based, intervention to promote exercise adoption (over 6 months) and maintenance (up to one year) among wheelchair users and includes descriptive data on participant characteristics at baseline. Participants were randomly assigned to either a staff-supported intervention group or a self-guided comparison group. The primary study aim is to assess the effectiveness of the multi-component behaviorally based intervention for promoting physical activity adoption and maintenance. The RCT will also assess the physical and psychosocial effects of the intervention and the complex interplay of factors that influence the effectiveness of the intervention. Therefore, the primary outcome derives from participant reports of weekly exercise (type, frequency, duration) over 52 weeks. Secondary outcomes collected on four occasions (baseline, 3 months, 6 months, 12 months) included physiological outcomes (VO(2) peak, strength), disability-related outcomes (pain, fatigue, participation), and psychosocial outcomes (exercise self-efficacy, exercise barriers, quality of life, depression, mood). This study will provide evidence regarding the effectiveness of a multi-component behaviorally based intervention for promoting exercise adoption among people with mobility impairments that necessitate wheelchair use.

Physical access in urban public housing facilities

BACKGROUND public housing facilities play an important role in housing individuals with physical disabilities, including older adults, who are unable to afford private housing. This study assessed general features of physical access in the common use areas of 14 federally subsidized, urban public housing facilities. METHODS fourteen public housing facilities were assessed by trained field assessors for 6 features of accessibility. RESULTS most housing facilities had at least 1 parking space designated with a vertical sign (86%), an entrance that was level or had a ramp (86%), and a 32-inch wide exterior door (71%). Half (50%) had a public restroom designated by signage as accessible, and most of these bathrooms had 32-inch-wide doorways and at least 1 grab bar near the toilet (86%). Most housing managers were able to identify building modifications that had been made to satisfy accessibility regulations. CONCLUSION the results suggest that relatively large proportions (14%-29%) of federally funded housing facilities are not complying with federal regulations. Better education and compliance are needed to ensure access for all in public housing facilities.

Impact of disability and chronic conditions on health

BACKGROUND Today one in five Americans have a disability and nearly half of Americans experiences a chronic condition. Whether disability results from or is a risk factor for chronic conditions, the combined effects of disability and chronic conditions warrants further investigation. OBJECTIVES Examine the added impact of chronic conditions among those with and without disability on self-reported health status and behaviors. METHODS 2009 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed to examine the association of disability with unhealthy behaviors and poor health stratified by number of self-reported chronic conditions (0, 1, or 2+). Linear and logistic regression models accounting for the complex survey weights were used. RESULTS Participants with disability were 6 times more likely to report fair/poor self-rated health, reported 9 more unhealthy days in a month and 6 more days in a month when poor health kept them from usual activities, were 4 times more likely to be dissatisfied with life, had greater odds of being a current smoker, and were less likely to be physically active. Presence of chronic conditions in addition to disability was associated, in a dose-response manner, with poor health status and unhealthy behaviors. CONCLUSIONS People living with both chronic diseases and disability are at substantially increased risks for poor health status and unhealthy behaviors, further affecting effective management of their chronic conditions. Multi-level interventions in primary care and in the community that address social and environmental barriers that hinder adults with disability from adopting more healthy lifestyles and improving health are needed.

Determining paralysis prevalence in the United States

BACKGROUND Estimates of paralysis vary widely, largely owing to a lack of standard definition and nontargeted survey approaches. Like other poorly understood conditions such as fibromyalgia, chronic fatigue, or chronic pain, paralysis falls outside the scope of clearly defined medical diagnosis, further complicating surveillance efforts. This inability to identify accurate prevalence makes developing policy interventions around the needs of many persons with these disabilities problematic. The objectives were to investigate how paralysis is being measured in the United States and to examine the validity of prevalence estimates based on current approaches. METHODS We reviewed existing measurement instruments and surveyed 139 agencies and organizations to determine how they capture paralysis data. RESULTS There is a widespread reliance on ICD coding or broad functional capabilities for most state or federal agencies. Many organizations serving consumers depend on state registries for discrete conditions in which paralysis is not directly measured. CONCLUSIONS Improved paralysis prevalence data will benefit from a more functional definition consistent with ICF guidelines, which can be part of future surveillance efforts at state and federal levels.

Exploring the health of women with mobility impairments

ABSTRACT This study examined health surveys of 109 midwestern women (mean age 44.6 ± 8.2 years) with impaired mobility to determine whether mobility impairment severity was related to self-reported health, health care use, and engaging in health behaviors. The study also assessed which health factors were associated with pain. Women with severe mobility impairments reported poorer physical functioning, but better mental health than less severely impaired women after controlling for age, disability duration, and/or bodily pain. Degree of mobility impairment level was not significantly related to health behaviors, except having a checkup in the past year; more moderately impaired women reported these visits than mildly impaired women. Furthermore, pain was significantly associated with social functioning, general health, and secondary conditions. The findings suggest that factors beyond impairment level, such as pain, age, and disability duration, are related to the health of mobility-impaired women.

Assessing Stress in Disability: Developing and Piloting the Disability Related Stress Scale

BACKGROUND Stress negatively influences health, but few scales capture unique stressors encountered by people with physical disability. OBJECTIVE/HYPOTHESIS Conduct a pilot study to develop and evaluate the factor structure of a stress measure targeting unique stressors facing people with physical limitations due to impaired movement of the upper and lower extremities. METHODS Development of the Disability Related Stress Scale (DRSS) included: (1) obtaining input regarding content and items from focus groups and outside experts and (2) piloting the instrument. Participants recruited from an independent living center attended a focus group or completed the pilot survey. The piloted measure was a 107 item two-part survey. Part 1 assessed stressors encountered over the past week and Part 2 assessed stressors encountered over the past six months. Participants included a convenience sample of 143 adults who experienced a physical limitation; 26 attended focus groups and 117 completed the instrument. Respondents were predominantly women (60%), Caucasian (58%), and unemployed (92%). Respondents were 50.51 ± 14.46 years old and had lived with their disability for 15.64 ± 13.04 years. RESULTS Exploratory factor analyses revealed a 4-factor solution for Part 1 and a 2-factor solution for Part 2 of the DRSS. Estimates of internal consistency (Part 1 Cronbachs α = .78-84; Part 2 Cronbachs α = .72) and factor loadings (.40-1.00 for Part 1; .43-.87 for Part 2) indicate adequate reliability for all subscales. CONCLUSIONS Preliminary results provide initial support for the instruments reliability and factor structure although further validation studies are warranted.

Disproportionate Prevalence Rate of Prisoners With Disabilities Evidence From a Nationally Representative Sample

Previous research suggests that prisoners have a higher rate of disability than non-institutionalized adults. This study used nationally representative data to update the prevalence rate, identify correlates of disability, and evaluate disability-related disparities in use of prison-based educational services, vocational programs, and work assignments. Data were obtained from 18,185 prisoners interviewed in the 2004 Survey of Inmates in State and Federal Correctional Facilities. Survey logistic regression procedures were conducted using Stata 13. Disability prevalence remained substantially higher among prisoners than among the non-institutionalized population. Prisoners were more likely to report specific learning, sensory, and speech-related disabilities than non-institutionalized adults. Prisoners with at least one type of disability had more criminogenic risk factors and come from a more disadvantaged background than prisoners without disability. Prisoners with disabilities were also less likely to utilize vocational programs and work assignments but were more likely to use educational programs than prisoners without disabilities. In summary, 41% of prisoners reported a disability, most commonly, learning disabilities. Prisoners with disabilities were identified as an at-risk group for recidivism, given their pre-incarceration experiences, and limited vocational and work-related training received in prison.