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MedGenMed. 2007; 9(3): 63.
Published online Sep 26, 2007.
PMCID: PMC2100137

Activity/participation Limitation and Weight Loss Among Overweight and Obese US Adults: 1999 to 2002 NHANES

Connie L. Bish, PhD, Nutrition and Health Science Program. Graduate, Heidi Michels Blanck, PhD, Nutrition and Health Science Program. Graduate, L. Michele Maynard, PhD, Mary K. Serdula, MD, Nutrition and Health Science Program. Graduate, Nancy J. Thompson, PhD, Nutrition and Health Science Program. Graduate, and Laura Kettel Khan, PhD, Nutrition and Health Science Program. Graduate

Abstract

Objective

To examine the prevalence and association of activity/participation limitation with trying to lose weight and weight loss practices (eating fewer calories, physical activity, or both) among overweight and obese adults in the United States.

Research Methods and Procedures

Eligible adults were 20 years of age or older with a body mass index (BMI) ≥ 25 kg/m2 (n = 5608) who responded to standard physical functioning questions included in the 1999–2002 National Health and Nutrition Examination Survey, a continuous survey of the civilian non-institutionalized US population.

Results

Obese (BMI ≥ 30) men with vs. without activity/participation limitations were more likely to try to lose weight (OR = 1.59, 95% CI 1.05–2.41). This was not the case for overweight women and men (BMI 25–29.9), or obese women. Among adults trying to lose weight, reducing calorie consumption was common (63%–73%, men, 67%–76%, women). Overweight women with vs without activity/participation limitations had significantly reduced likelihood of attaining recommended physical activity (OR = 0.56, 95% CI 0.36–0.89). Obese adults were more likely to try to lose weight if they attributed their limitation to body weight (OR = 1.78, 95% CI 1.11–2.88) or diabetes (OR = 1.86, 95% CI 1.01–3.43) compared to other causes. Overweight and obese adults who attributed activity/participation limitations to mental health, musculoskeletal, or cardiovascular problems were equally likely to attempt weight loss when respondents with each condition were compared to respondents without the condition.

Discussion

These results verify the importance of adequate subjective health assessment when developing individual weight loss plans, and may help guide weight management professionals in the development and delivery of more personalized care.

Keywords: overweight, obesity, weight loss, diabetes, disability

Introduction

Obesity is a risk factor for the development and progression of numerous chronic conditions,[1] including type II diabetes,[2] osteoarthritis,[3] and depression.[4] These comorbid conditions can contribute to long-term activity restriction, physical disability, and overall activity/participation limitation as detailed in a list of usual domains of activity and participation provided by the International Classification of Functioning, Disability and Health.[5] Obese men and women of all ages are more likely than normal weight individuals to report activity/participation limitations specific to performing basic and instrumental activities of daily living and other measures of independent living.[615] Analysis of the NHANES Epidemiologic Follow-up Study found that obesity was associated with higher levels of both upper- and lower-body disability, and normal weight persons who became obese had higher disability at subsequent follow-up points.[9]

Modest weight loss can improve obesity-related conditions including diabetes, osteoarthritis, depression, poor quality of life, and disability.[3,1620] An individual's objective medical condition (eg, weight, diabetes, hypertension) and subjective perception of their health (eg, difficulty walking, low energy level, difficulty in social situations) are both important elements in assessing readiness for weight loss and directing medical treatment.[21] Because obesity is a complex condition, assessment of psychological, social, and medical reasons for trying to lose weight is important.[22] Although trying to lose weight is a concern for many Americans,[2326] motivation and readiness for trying to lose weight are not fully understood and can include perceived appearance or the desire to improve health,[27,28] and may differ by sex.[29] The prevalence of trying to lose weight has consistently been shown to be higher among women than men.[2326]

The objectives of this study were to examine the prevalence of general activity/participation limitation, the prevalence of activity/participation limitation caused by specific health problems, and associations between activity/participation limitation and weight loss practices among those who were trying to lose weight in a nationally representative sample of overweight and obese adults.

Methods

Data from the 1999 to 2002 National Health and Nutrition Examination Survey (NHANES), a continuous annual survey of the civilian non-institutionalized United States population (adults 20 years of age or older), were used. NHANES uses a complex, stratified, multistage probability sampling design; details of sample design and interview procedures have been published previously.[30,31]

Outcomes and Covariates

Limitation and causal condition measures

Activity/participation limitations were assessed by activities of daily living (ADL), and instrumental activities of daily living (IADL) that include mobility and social participation.[32] ADL includes personal care such as bathing or showering, dressing, getting in or out of bed or a chair, using the toilet, and eating. IADL refers to independent living that includes preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, or using the telephone. Social participation includes items such as going out to movies or events, or leisure activities at home. Activity/participation limitation was determined by the degree of difficulty (no difficulty, some difficulty, much difficulty, or unable) reported by respondents during these activities due to ‘health problems.’ A ‘health problem’ was defined as any long-term physical, mental, or emotional problem or illness (not including pregnancy). Nineteen functional items (Table 1) were assessed and individuals were classified as activity/participation limited if they responded to having any level of difficulty with any of the 19 items. Respondents who reported no difficulty for all items were classified with no limitation.

Table 1
Potential Activity/Participation Limitations Associated With Long-Term Physical, Mental, or Emotional Problem or Illness: National Health and Nutrition Examination Survey 1999–2002

Individuals classified as activity/participation limited were then asked to identify as many as 5 of 18 health conditions that caused their limitations.[30,31] The 5 causal domains associated with obesity and their corresponding self-reported health conditions used in this analysis were musculoskeletal (arthritis or rheumatism, back or neck problem or fractures, bone or joint injury); cardiovascular (heart problem, hypertension, or stroke problem); body weight (weight problem); mental health (depression, anxiety, emotional problem); and diabetes. Birth defects, cancer, hearing problem, lung or breathing problems, mental retardation, other injury, senility, vision or seeing problem or other impairments that have either no or inconsistent relationships with body weight were not included.

Trying to lose weight

A weight history was requested to determine which adults were trying to lose weight. Respondents were initially asked, “What do you weigh without clothes or shoes?” and “How much did you weigh a year ago?” Based on these self-reported weight questions, if respondents lost ≥ 10 pounds from a year ago they were asked, “Was the change between your current weight and your weight a year ago intentional?” Those who said “yes” were defined as trying to lose weight. Respondents who had not lost ≥ 10 pounds were asked, “During the past 12 months, have you tried to lose weight?” Those who answered “yes” were also defined as trying to lose weight.

Weight loss practices

Recommended dietary weight loss practices were assessed in accordance with the National Heart, Lung, and Blood Institute's (NHLBI) Clinical Guidelines for the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,[33] which recommends consuming fewer calories for weight loss. Caloric restriction was determined by the question, “How did you try to lose weight?” Response options included ate less food, switched to foods with lower calories, ate less fat, exercised, skipped meals, ate diet foods or products, used a liquid diet formula such as Slim-Fast or OPTIFAST, joined a weight loss program such as Weight Watchers, Jenny Craig, Tops, or Overeaters Anonymous, took prescription or non-prescription pills, took laxatives or vomited, drank a lot of water, followed a special diet such as Dr. Atkins or Pritikin, and other. The responses were not mutually exclusive, and our goal was to adhere to the NHLBI guideline for reduced calories; therefore, we used the broad response categories. Respondents who answered that they “ate less food” or “switched to foods with lower calories” were categorized as consuming fewer calories. To meet physical activity recommendations for health, the respondent must have reported at least moderately intense physical activity ≥ 5 times per week for an average of ≥ 30 minutes per bout, vigorous-intensity physical activity ≥ 3 times per week for an average of ≥ 20 minutes per bout, or both during the previous month.[34,35] Survey respondents who met the reduced-calorie and physical-activity criteria were categorized as meeting both recommendations.

Overweight and obesity

Overweight and obesity were defined using body mass index (BMI: weight [kilograms]/height [meters]2). Overweight (BMI 25.0–29.9 kg/m2) and obese (BMI ≥ 30.0 kg/m2) were categorized in accordance with the NHLBI Clinical Guidelines for the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.[33]

Demographics

Covariates of interest were gender, age in years (continuous), race (non-Hispanic white, non-Hispanic black, and Hispanic), level of education (less than high school, high school graduate, more than high school), and smoking status (current, former, and never). The NHANES Hispanic sample was primarily Mexican American (MA), but included a small proportion of other Hispanic groups (MA = 1461, Other Hispanic = 309). Smoking was defined as current (≥ 100 lifetime cigarettes and currently smoking), former (≥ 100 lifetime cigarettes and not currently smoking), and never.

Analytical Sample

NHANES 1999–2002 respondents aged 20 years or older with a BMI ≥ 25.0 kg/m2 who participated in the examination component of the survey were eligible for inclusion in this study (n = 6145). Individuals with BMI < 25.0 kg/m2 were excluded from analysis because they should not be advised to lose weight.[33] Respondents with incomplete information regarding weight history (n = 11), pregnancy (or currently pregnant) (n = 409), race, education, or smoking status (n = 117) were excluded from this study. The final analytic sample totaled 5608 people (2745 women and 2863 men).

Statistical Analysis

Means and frequencies were calculated to describe the population. Logistic regression was used to estimate adjusted odds ratios for trying to lose weight in relation to overall activity/participation limitation stratified by gender, BMI, and controlling for potential confounders (age, race, education, and smoking). Among respondents who were trying to lose weight, logistic regression was used to estimate the adjusted odds ratio for each weight control practice in relation to activity/participation limitation, and was also stratified as described above. Among respondents with activity/participation limitations, logistic regression was used to test associations between trying to lose weight and specific limitations attributed to musculoskeletal problems, cardiovascular problems, body weight, mental health, or diabetes. SAS (version 9.1, SAS Institute, Cary, NC) and SAS callable SUDAAN (version 9.0, Research Triangle Institute, Research Triangle Park, NC) were used for the statistical analysis to account for the complex sampling design and to calculate weighted estimates. All analyses included sample weights that accounted for the unequal probabilities of selection, oversampling, and non-response. Two-sided hypotheses were assessed and statistical significance was set at P < .05 for all comparisons.

Results

Overall, the weighted sample of overweight and obese adults was 48.3% women and 51.7% men with a mean age of 51.5 years; their general characteristics are shown in Table 2 . The majority of respondents were non-Hispanic white (72.8%), had higher than a high school education (50.2%), and were non-smokers (28.0% former, 50.2% never). The overall prevalence of trying to lose weight in the past 12 months was 51.2%. The overall prevalence of activity/participation limitation was 29.2%. Among adults who reported limitations, musculoskeletal problems were the most common causal domain (63.8%), followed by cardiovascular issues (13.9%), body weight (13.5%), mental health (9.4%), and diabetes (6.1%) (data not shown). Among individuals who had activity/participation limitations and reported trying to lose weight, 68.5% reported calorie reduction, 35.5% attained recommended weekly physical activity and 24.7% combined reduced calories with recommended physical activity (data not shown).

Table 2
Characteristics of Overweight and Obese* US Adults Aged 20 Years or Older: National Health and Nutrition Examination Survey 1999–2002

Among those with activity/participation limitation, the prevalence of trying to lose weight was 34% and 60% for overweight and obese men, respectively, and 42% and 59% for overweight and obese women, respectively (Table 3). Compared to men without activity/participation limitation, obese men with activity/participation limitation were 1.6 times more likely to be trying to lose weight. Among overweight men and all women, activity/participation limitation was not significantly associated with trying to lose weight. Among those trying to lose weight, activity/participation limitation was not associated with reported us of reduced calories (Table 4). Attainment of recommended physical activity was a less common practice than reduced calories. The only association between having an activity/participation limitation and attaining recommended weekly physical activity was among overweight women; specifically, they were half as likely to have attained recommended physical activity (OR = 0.56; 95% CI, 0.36–0.89; Table 4). Recommended physical activity combined with fewer calories was less prevalent than the previous 2 practices, for both men and women (Table 4), and no significant associations were found.

Table 3
Prevalence and Odds of Trying to Lose Weight by Activity/Participation Limitation among Overweight and Obese* US Adults Aged 20 Years and Older: National Health and Nutrition Examination Survey 1999–2002
Table 4
Prevalence and Odds of Weight Loss Behavior by Activity/Participation Limitation Among Overweight and Obese* US Adults Aged 20 Years and Older Who Were Trying to Lose Weight: National Health and Nutrition Examination Survey 1999–2002

The prevalence of limitations by causal domain and the odds of trying to lose weight among those reporting an activity/participation limitation are shown in Table 5 . A musculoskeletal problem was the most prevalent causal domain for limitations among both overweight (60.1%) and obese (66.9%) adults. Among overweight persons with a limitation, there was no association between the reason for the limitation and trying to lose weight (Table 5). Among obese persons with a limitation there was a significant association between diabetes and trying to lose weight (OR = 1.86; 95% CI, 1.01–3.43), and between a weight problem and trying to lose weight (OR = 1.78; 95% CI, 1.11–2.88).

Table 5
Prevalence and Odds of Trying to Lose Weight by Limitation Causal Domain Among Overweight and Obese* US Adults Aged 20 Years and Older With Self-Reported Activity/Participation Limitation: National Health and Nutrition Examination Survey 1999–2002 ...

Discussion

Activity/participation limitation was evaluated in this population as a subjective measure of the ability to perform everyday activities and, therefore, one measure of overall health.[5] Approximately 30% of overweight and obese adults reported some degree of limitation. Consistent with other studies,[615] as BMI increased, the prevalence of limitations increased. Furthermore, obese, but not overweight, men with limitations had increased odds of trying to lose weight; no association was found among overweight or obese women. Other studies have found that when men consider their health to be poor or have a weight-related medical influence they engage in health improvement behaviors such as trying to lose weight.[3639] A recent study that evaluated NHANES data found that obese men with increasingly poor physical health-related quality of life (HRQOL) were more likely to try to lose weight.[36] A National Health Interview Survey study found that adults with disabilities were as likely to attempt weight loss as adults without disabilities,[40] and the previously mentioned NHANES study found that high proportions of women reported trying to lose weight at all HRQOL levels.[36]

Among adults who were trying to lose weight, use of reduced calories for weight loss was common and not significantly related to activity/participation limitation. Among overweight women, those with limitations had reduced odds of attaining recommended weekly physical activity. The low overall prevalence of meeting recommended physical activity in our study (whether limited or not), particularly among women, suggests a need for continued public health efforts to tailor and promote physical activity for the overweight and obese population.

Among obese adults, activity/participation limitation attributed to body weight or diabetes increased the odds of trying to lose weight, but limitations attributed to other causes did not. Individuals who attribute their limitations to weight or diabetes may represent sub-populations who with proper goal setting, weight loss guidance, and support are more likely to engage in a weight loss effort. Individuals who have been diagnosed with diabetes are generally counseled that weight control is important for disease management.[41] The possibility also exists that adults who attribute their limitations to body weight may believe it is socially desirable to respond that they are trying to lose weight.

Over 8 million Americans suffer from arthritis, the primary cause of physical disability.[42] Weight loss has been shown to diminish symptoms of arthritis.[16] Although arthritis was the primary cause of limitation for those in the musculoskeletal causal domain in our study, individuals with vs without this limitation were equally likely to be trying to lose weight. Therefore, this large subpopulation of adults with limitations could benefit from support and guidance in appropriate weight loss strategies. Respondents who attributed vs did not attribute their limitation to a mental health condition or to a cardiovascular condition were also equally likely to be trying to lose weight.

Several study limitations must be considered. The cross-sectional design of this study limits any conclusions regarding causal relationships; it is impossible to determine the direction of the association between activity/participation limitations, trying to lose weight, and weight loss practices. Furthermore, all information except height and weight was self-reported. Self-report is often influenced by social desirability.[43] For example, persons with known disabilities reported significantly fewer days' limitation from in-person vs. telephone interviews.[44] NHANES limitation questions were determined during the interviewer administered household interview. Physical activity may be underestimated because only leisure-time activities were ascertained (no occupational or transportation activity), and no information was collected on actual caloric intake. The sample size provided adequate power to stratify by sex for the initial evaluation of limitation and trying to lose weight, but not for evaluation of the association between limitations within causal domains and trying to lose weight. Sample size and the large percentage of non-Hispanic white respondents (73%) also limited the ability to assess associations between limitations and trying to lose weight stratified by race/ethnicity.

The greatest strength of the current study is the use of a nationally representative sample rather than obese patients seeking medical care or weight loss treatment. In addition, the ability to examine within causal domains adds to the scant knowledge published in this area. Measured height and weight was also a strength that eliminated the chance of misclassification of respondents by body weight status.

This study of data from a large national surveillance system supports the importance of adequate subjective health assessment such as activity/participation limitation when developing individual weight loss plans. Research has shown that obese individuals who seek weight loss treatment are not homogeneous[4548]; therefore, identifying potential influential factors related to an individual's weight control efforts may help guide weight management professionals in the development and delivery of weight control programs that are personalized to individual weight loss needs.

Acknowledgments

The authors thank Cathleen Gillespie for her statistical analysis support for this project.

Notes

Funding Information

This research was supported in part by an appointment of the first author to the Research Participation Program at the Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and the CDC.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of CDC.

Footnotes

Reader Comments on: Activity/participation Limitation and Weight Loss Among Overweight and Obese US Adults: 1999 to 2002 NHANES See reader comments on this article and provide your own.

Readers are encouraged to respond to the author at vog.cdc@2zea or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication as an actual Letter in MedGenMed via email: ude.drofnats@nemulbp

Contributor Information

Connie L. Bish, Division of Biological and Biomedical Sciences, Graduate School of Arts and Sciences, Emory University, Atlanta, Georgia; Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

Heidi Michels Blanck, Division of Biological and Biomedical Sciences, Graduate School of Arts and Sciences, Emory University, Atlanta, Georgia; Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

L. Michele Maynard, Division of Nutrition. Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

Mary K. Serdula, Division of Biological and Biomedical Sciences, Graduate School of Arts and Sciences, Emory University, Atlanta, Georgia; Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

Nancy J. Thompson, Division of Biological and Biomedical Sciences, Graduate School of Arts and Sciences, Emory University, Atlanta, Georgia; Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Laura Kettel Khan, Division of Biological and Biomedical Sciences, Graduate School of Arts and Sciences, Emory University, Atlanta, Georgia; Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia Author's email: vog.cdc@2zea.

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