Disability and Health Journal 1 (2008) 89e98

www.disabilityandhealthjnl.com

Overweight and obesity in women with physical disabilities:Associations with demographic and disability characteristics

and secondary conditions

Margaret A. Nosek, Ph.D.a,*, Susan Robinson-Whelen, Ph.D.a, Rosemary B. Hughes, Ph.D.b,Nancy J. Petersen, Ph.D.c, Heather B. Taylor, Ph.D.d, Margaret M. Byrne, Ph.D.e,

Robert Morgan, Ph.D.caCenter for Research on Women with Disabilities, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA

bRural Institute on Disabilities, University of Montana, Missoula, MT 59812, USAcHouston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, Department of Veterans Affairs Medical

Center, Houston, TX 77021; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX 77021, USAdDivision of Developmental Pediatrics, University of Texas Health Science Center, Houston, TX 77030, USA

eDepartment of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL 33136, USA

Received 18 January 2007; received in revised form 9 April 2007; accepted 13 July 2007

Abstract

Background: This cross-sectional study was designed to examine weight in association with demographic and disability characteristicsand secondary conditions in a sample of community living women with physical disabilities.

Methods: 443 predominantly ethnic minority women with physical disabilities were recruited through public and private health clinicsand community organizations. They completed questionnaires including measures of body mass index and a health conditions checklist.

Results: Data showed that nearly three-quarters of the sample were overweight (26.6%) or obese (47.6%) with 14% extremely obese.Obesity was highest among middle aged women (aged 45-54, 52.7%; aged 55-64, 52.5%; compared to aged 18-44, 37.8%; or aged >65,39.1%). Black (84.0%) and Hispanic women (83.8%) were more likely to be overweight or obese compared to non-Hispanic white women(56.7%). Women with joint and connective tissue diseases and women with more extensive functional limitations were more likely to haveexcess weight. Disability factors were more strongly associated with excess weight than demographic factors other than age. Weight clas-sification was significantly related to whether or not the women had ever had diabetes or blood pressure problems.

Diabetes was reported 4 times as often as among women in general (36.3% versus 8.9%), and hypertension nearly twice as often (56.2%versus 30.9%).

Conclusions: These findings indicate extremely high rates of overweight and obesity in women with physical disabilities, a growingpopulation greatly in need of effective weight management interventions. Overweight and obesity in combination with disability in womenwas associated with disproportionately high rates of diabetes and hypertension. � 2008 Elsevier Inc. All rights reserved.

Keywords: Disabled persons; Minority groups; Overweight; Obesity; Rehabilitation; Women

Overweight and obesity represent a major health dispar-ity between women with disabilities and women withoutdisabilities. Chapter 19 of Health People 2010 [1] observesthat, based on data collected between 1991 and 1994, only35% of women with disabilities were at a healthy weightcompared to 45% of women without disabilities. A 2002

No commercial party having a direct financial interest in the results of

the research supporting this article has or will confer a benefit upon the au-

thors or upon any organization with which the authors are associated.

* Corresponding author: 1475 West Gray, Suite 165.

E-mail address: mnosek@bcm.edu (M.A. Nosek).

1936-6574/08/$ e see front matter � 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.dhjo.2008.01.003

analysis of Behavioral Risk Factor Surveillance Survey(BRFSS) data from eight states [2] showed that personswith disabilities had higher rates of obesity than those with-out disabilities, with women showing greater disparitiesthan men (women with disabilities, 29.1%, and womenwithout disabilities, 15.3%; men with disabilities, 25.5%,and men without disabilities, 17.7%). When analyzed byrace and ethnicity, the greatest disparities existed betweenpeople with disabilities who were Hispanic (31.3% versus16.5% of Hispanics without disabilities), followed by black(35.8% versus 24.0% for blacks without disabilities), andwhite (25.7% versus 15.5% of whites without disabilities).

90 M.A. Nosek et al. / Disability and Health Journal 1 (2008) 89e98

A study of people with physical and cognitive disabilities inone major metropolitan area [3] found that minority womenwith disabilities had the greatest risk of being overweightand obese and were nearly 8 times more likely to be inthe category of extreme obesity compared with whitewomen without disabilities. Black women with disabilitieshad the highest body weights compared with other ethnicgroups. The likelihood of being in the category of extremeobesity was approximately 4 times higher for women withdisabilities compared with men with disabilities and almost5 times higher than for women without disabilities. Al-though individuals with disabilities had a greater risk ofbeing overweight, obese, or extremely obese, minoritywomen with disabilities presented the most serious con-cern, with nearly one third of the group being in the ex-treme obesity category. These findings reinforce results ofan analysis of the 1994-1995 National Health InterviewSurvey Disability Panel [4], which found that women withthree or more functional limitations were significantly morelikely to be overweight than women without limitations(43.2% versus 21.6%).

Obesity and disability can be viewed from two distinctperspectives. Obesity, in a high percentage of cases, canlead to disability, most often from arthritic conditions thatresult from excessive wear and tear on joints. This is espe-cially evident in individuals who are overweight or obeseand also have diabetes. Their risk for lower limb and mobil-ity impairment is extremely high. Not all persons who areobese, however, have functional limitations or disabilities.One large longitudinal study found that disability riskwas higher for obese persons, but being overweight wasnot consistently associated with higher disability [5]. An-other perspective of obesity and disability is that personswho have a preexisting physical impairment are predis-posed to being overweight and obese for a variety of rea-sons. In addition to the risk factors for obesity faced bythe general population, risk factors for these individualsalso include altered body composition and limitations inhealth-promoting behaviors associated with socioenviron-mental barriers.

The mechanisms underlying the increased prevalence ofobesity in people with physical disabilities relate to patho-physiological changes in body composition and energy me-tabolism, physical inactivity, and muscle atrophy [6].Compared with able-bodied individuals, people with spinalcord injury (SCI) have a 3- to 5-fold higher risk of develop-ing type 2 diabetes mellitus, which may be associated withincreased fat mass. Evidence suggests that leptin regulatesbody adiposity through the sympathetic nervous system,which is impaired in people with high lesion SCI [7].

There are many reasons why good nutrition and weightcontrol are problematic for women with disabilities. Astudy of Canadian women with physical disabilities linkedpoor nutritional behaviors with being too tired to cook, nu-tritious foods being too expensive, lack of desire or willpower, difficulty shopping, and not enough time for hired

attendants to shop or prepare food [8]. Depending on themedications prescribed, weight gain can be a serious issuefor women with disabilities whose primary or secondarydisabling health conditions often involve seizures, inflam-mation, depression, anxiety, diabetes, and/or hypertension.Many of the pharmaceutical agents used for treating thoseconditions are linked with unwanted weight gain [9,10].Environmental barriers undoubtedly help explain the dis-proportionately high rates of obesity in women with dis-abilities who face the pervasive inaccessibility of exercisefacilities [11-15], cost issues [12,15-17], and lack of knowl-edge about safe exercises for certain disabilities [13,18,19].Finally, women with disabilities using exercise facilitiesreport personal barriers related to a fear of failure [20,21],embarrassment, or attracting stares [22].

In the context of disability, obesity has been examined asa ‘‘secondary condition.’’ Defined as highly preventablemedical, physical, cognitive, emotional, or psychosocialcomplications of physical impairment [23-26], secondaryconditions are strongly related to adverse outcomes in qual-ity of life and health for people with disabilities [23,24,27].Obesity as a common secondary condition in people withphysical disabilities has been documented in cross-disabil-ity samples [28] and samples of individuals with cerebralpalsy [29], polio [30], multiple sclerosis (MS) [31], SCI[32,33], and neuromuscular disorders [34]. Obesity is oftenassociated with other secondary conditions, including pain,hypertension, diabetes, and depression, that further contrib-ute to functional limitations [25].

Studies have documented the association of obesity withelevated metabolic risk factors in people with disabilities;unfortunately, these studies have been conducted exclu-sively on men or on mixed samples that did not analyze re-sults by gender. A study of a small sample of people withneuromuscular disorders [35] (NMD group) found thatmost were more obese and more sedentary than nondis-abled controls and also had numerous cardiovascular andmetabolic risk factors, with low high-density lipoprotein(HDL) levels, high body mass index (BMI), and high tri-glyceride levels being the most common. Additionally,55% of the NMD group satisfied the criteria for metabolicsyndrome, versus 0% in the nondisabled control group. Theauthors concluded that persons with NMDs are at high riskfor developing chronic diseases resulting from obesity anda sedentary lifestyle. A study of men with SCI linked ab-dominal circumference and serum HDL cholesterol and tri-glycerides as well as the total cholesterol [36]. No knownstudies have examined metabolic risk factors in womenwith physically disabling conditions.

The current study examined weight in association withdemographic and disability characteristics and other sec-ondary conditions. Our research questions were (1) Whatis the prevalence of overweight and obesity in a sampleof community-living women with physical disabilities?(2) What is the association of abnormally high weight withdemographic and disability characteristics? (3) What is the

91d Health Journal 1 (2008) 89e98

association of higher-than-normal BMI and other healthconditions?

Methods

Sample and procedures

Women were eligible for the study who (1) were at least18 years old, (2) lived in the local metropolitan area, (3)had the diagnosis of a physical disability or any conditionthat causes a limitation in one or more major life activitiesincluding mobility and self-care and home management,and (4) had no known cognitive impairments, mental healthproblems, or problems understanding English or Spanishthat would significantly impair their ability to respond toquestions during an interview. Women were excluded fromthe study who presented with current (1) substance abuse,(2) suicidality, (3) plans to leave the metropolitan areawithin the following year, (4) no telephone, and/or (5) a dis-ability of less than 1-year duration. After obtaining institu-tional review board approval, participants were recruitedthrough private and public health clinics, the database ofwomen with disabilities who had earlier expressed interestin participating in future research studies, and various com-munity organizations. Interested women were informed, intheir preference of English or Spanish, that the study soughtto examine disability-related characteristics, health condi-tions, and health care expenses among women with physi-cal disabilities. The women were also informed that theywould be asked to complete seven approximately30-minute long interviews (an initial interview and sixbimonthly telephone interviews) over the course of a year.

A total of 717 women were invited to participate ina screening interview. Of these, 230 were not screened (rea-sons included no time, did not feel well, transportation dif-ficulties, family waiting, etc.), 37 reported that they did notmeet the requirements before screening, and 7 were foundineligible during the screening interview (4 lived outsidethe metropolitan area; 3 had had a disability for less than1 year). A sample of 443 women met the study criteria (par-ticipation rate, 62%), gave written informed consent, andparticipated in the enrollment interview.

Data collection

Data were collected by means of survey questionnairesadministered in structured interviews. The questionnaireswere translated from English to Spanish and back-trans-lated to English for quality assurance, to be available tothose who preferred to be interviewed in Spanish. The fol-lowing measures were used to collect data pertaining todemographics, disability status, and health conditions.

DemographicsBasic demographic questions included age, race and eth-

nicity, educational level, marital status, sexual orientation,

M.A. Nosek et al. / Disability an

employment status, personal and household income, andhealth insurance information.

Disability-related informationInformation was gathered about disability including dis-

ability type, age at onset, and duration. Disability severitywas measured by the 10-item Physical Functioning sub-scale of the Medical Outcomes Survey 36-Item Short-FormHealth Survey (SF-36) [37]. To determine primary disabil-ity, participants were asked to indicate their disabling con-ditions from a list of 16 physically disabling conditions plusan open-ended ‘‘other condition.’’ If more than one condi-tion was endorsed, participants were asked to choose themost limiting condition, which was then labeled theirprimary disability.

Secondary conditionsThe Health Conditions Checklist includes 42 secondary

and chronic health conditions and constitutes an adaptationof the Secondary Condition Surveillance Instrument byRavesloot et al. [38]. We excluded conditions that resultedfrom or reflected participants’ interaction with their envi-ronment, such as difficulties with access and equipment-related injuries, and added female-specific conditionsincluding yeast infection, vaginal infection, and menstrualproblems. As a result of limited lower-limb mobility, useof certain medications, and compromised immune systems,some women with disabilities experience vaginal infections[39] and menstrual problems [40] that may not necessarilyoccur without the presence of the primary disability.

The Health Conditions Check Lists asks participants torate the extent to which each health condition affects theiractivity and independence (interference rating) in the past 2months by using 0 for ‘‘no or an insignificant problem,’’ 1for a ‘‘mild or infrequent problem,’’ 2 for a ‘‘moderate oroccasional problem,’’ 3 for a ‘‘significant or chronic prob-lem,’’ and 4 for ‘‘never had this condition.’’ We classifiedrespondents as endorsing the condition if they respondedwith 1, 2, or 3.

Prevalence of secondary conditions at enrollment wascalculated for each health condition by dividing the numberof women endorsing the condition as at least a mild or in-frequent problem in the past 2 months (interference ratingof 1-3) by the total number of participants. It is likely thatthe prevalence statistics calculated in this way yielded un-derestimations because the rating of 0, which representednot currently having the condition as well as having a con-dition that had caused no problems in the past 2 months,was not considered an endorsement of the condition.

Body mass indexWomen were asked to self-report their body weight and

height, which were used to calculate BMI (in kg/m2) [40].

92 M.A. Nosek et al. / Disability and Health Journal 1 (2008) 89e98

Results

Characteristics of the sample

The demographic and disability characteristics of the di-verse sample of 443 women with disabilities are presentedin Table 1. The majority were aged 52 and older, and onlyabout one third were married or living as married. Althoughnearly 40% of the participants did not provide informationon their household income, this appeared to be a very lowsocioeconomic sample with the median annual householdincome barely exceeding $11,000. Although relatively welleducated, only 17% of the women were gainfully em-ployed. Women in this sample generally had long-term, se-vere physical disabilities. The mean duration was morethan a decade, with most having acquired disability at mid-life. About half had joint and connective tissue disorders,and the other half had SCI, stroke, muscular sclerosis, orpostpoliomyelitis. Nearly 70% of the women required atleast one assistive device. Scores on the SF-36 physicalfunctioning subscale were well below the U.S. norms forphysical functioning in women (mean 6 standard devia-tion, 23.43 6 24.24 versus mean, 81.47 6 24.60) [37].

Table 1

Demographic and Disability Characteristics of the Sample (N 5 443)

Age (y) 52.97 6 11.29 (18-83)

Race and ethnicity

Non-Hispanic white 35.4 (157)

Non-Hispanic black 33.9 (150)

Hispanic 23.7 (105)

Other 7.0 (31)

Interviews conducted in Spanish 11.7 (52)

Education

Graduated from high school or

GED diploma

12.9 (570)

High school graduate and college/

technical school

28.2 (125)

College degree or more 42.2 (187)

Working for pay 16.7 (74)

Income

Median personal, annual ($) 7086 (mean, 9696 6 11,599)

Median household, annual ($) 11,364 (mean, 21,445 6 28,410)

Currently married or living as married 35.7 (158)

Heterosexual 97.5 (422)

Primary disability

Duration (y) 12.50 6 13.59 (1-72)

Age at disability onset (y) 40.52 6 16.55 (0-76)

Joint and connective tissue diseases 48.5 (215)

Spinal cord injury 12.0 (53)

Stroke 10.2 (45)

Multiple sclerosis 9.5 (42)

Polio 5.6 (25)

Other 14.2 (63)

Assistive device use

Used at least 1 assistive device 68.6 (304)

Used a power wheelchair 12.2 (54)

Manual wheelchair 20.1 (89)

Walker 22.1 (98)

Values are given as mean 6 SD (range) or % (n) or as indicated.

GED, General Educational Development.

Prevalence of overweight and obesityThe mean weight of the sample at baseline was 183.3

pounds (SD 5 56.1, SE 5 2.7) with a range of 64 to 500pounds. The mean BMI at baseline was 31.1 kg/m2 (SD 5

9.2 kg/m2, SE 5 0.44 kg/m2) (median 5 29.7 kg/m2)with a range of 14.1 to 73.5 kg/m2. Using current nationalBMI standards (overweight 25.0 < 29.9 kg/m2, obese>30.0 kg/m2, extremely obese > 40.0 kg/m2), nearly threequarters of the sample were classified as either overweight(26.6%) or obese (47.6%) with 13.9% of the sample classi-fied as extremely obese. There were a very small number ofwomen (n 5 14, 3.2% of the total sample) whose BMIwas slightly below the cutoff point for normal weight(!18.5 kg/m2). Given their small number, this group wasincorporated into the normal weight group.

Association with demographicand disability characteristics

As shown in Table 2, weight classification was signifi-cantly related to age (c2 [df 5 6; N 5 443] 5 14.26,p < .03), with a higher percentage of women aged 45 to54 and 55 to 64 classified as obese (52.7% and 52.5, respec-tively) relative to those either younger (37.8%) or older(39.1%). Race or ethnicity was also related to weight clas-sification, with a greater percentage of black (84.0%) and

Table 2

Association of Weight Category With Demographic and Disability Char-

acteristics (N 5 443)

% (n) Normal Overweight Obese

Age (y)

18-44 20.3 (90) 37.8% 24.4% 37.8%

45-54 33.9 (150) 21.3% 26 .0% 52.7%

55-64 31.4 (139) 19.4% 28.1% 52.5%

65þ 14.4 (64) 32.8% 28.1% 39.1%

Race and ethnicity

Non-Hispanic white 35.4 (157) 43.3% 15.3% 41.4%

Black 33.9 (150) 16.0% 32.0% 52.0%

Hispanic 23.7 (105) 16.2% 36.2% 47.6%

Other 7.0 (31) 16.1% 25.8% 58.1%

Education

Less than high school

degree

12.9 (57) 14.0% 36.8% 49.1%

Graduated from high

school or GED

28.2 (125) 17.6% 26.4% 56.0%

High school graduate

and college/

technical school

42.2 (187) 28.3% 24.6% 47.1%

College degree

or more

16.7 (74) 41.9% 24.3% 33.8%

Primary disability

Joint and connective

tissue diseases

48.5 (215) 16.7% 26.0% 57.2%

Spinal cord injury 12.0 (53) 37.7% 22.6% 39.6%

Stroke 10.2 (45) 26.7% 35.6% 37.8%

Multiple sclerosis 9.5 (42) 61.9% 26.2% 11.9%

Polio 5.6 (25) 20.0% 32.0% 48.0%

Other 14.2 (63) 23.8% 23.8% 52.4%

GED, General Educational Development.

M.A. Nosek et al. / Disability and

Hispanic (83.8%) women compared to non-Hispanic whitewomen (56.7%) exceeding normal weight (c2 [df 5 4; N 5

412] 5 41.88, p < .001).Weight classification was also related to educational

level (c2 [df 5 6; N 5 443] 5 21.78, p < .001), with thosehaving completed college being more likely to be of normalweight (41.9%) than those with fewer years of education(see Table 2). Because educational level and racial/ethnicgroup (non-Hispanic black, Hispanic, non-Hispanic white)are related (c2 [df 5 6; N 5 412] 5 131.07, p < .001),it is very difficult to disentangle the influence of educa-tional level and racial/ethnic group on weight and weightclassification. However, ethnic/racial group made a signifi-cant independent contribution to the variance in BMI[DR2 5 0.02, F(2,406) 5 3.75, p < .02], over and abovethe influence of educational level in a multiple regressionanalysis using BMI as a continuous variable with the threeprimary ethnic/racial groups and the four educationalgroups represented by two and three dummy coded vari-ables, respectively. In contrast, educational level failed tomake a significant independent contribution to BMI overand above the influence of ethnic/racial group [DR2 5 .01,F(3,406) 5 1.64, p 5 .18]. Weight classification was alsorelated to household income, with the mean income ofthose classified as normal weight nearly twice that of thoseclassified as obese [mean incomes, $32,060, $19,716, and$16,318 for normal, overweight, and obese women, respec-tively; F(2,268) 5 7.407, p ! .001].

We next examined the relation between weight classifi-cation and disability-related variables. Weight classificationwas not significantly related to duration of disability[F(2,442) 5 2.03, p < .09]. BMI category was not associ-ated with the extent of functional limitations as measuredby the SF-36 Physical Functioning scale [F(4,442) 5 .44,p 5 .78].

Disability type was significantly related to weight classi-fication [c2 (df 5 20; N 5 438) 5 59.68, p < .001] (seeTable 2). Women with MS were the least likely to be over-weight or obese (38.1%), and women with joint and con-nective tissue disease as their primary disabling condition(83.4%) were the most likely to be overweight or obese.Consistent with the greater prevalence of MS among whitewomen in the larger U.S. population, the majority ofwomen with MS in our sample were white (71.4%). Eth-nic/racial composition of this group cannot fully accountfor the lower rates of overweight and obesity in this sub-sample of women with MS as differences in weight classi-fication emerged even when race was held constant byconstraining the analysis to non-Hispanic white participants[c2 (df 5 20; N 5 156) 5 35.38, p < .02].

Joint or connective tissue diseases consist of a diversegroup of conditions, including fibromyalgia, lupus, osteoar-thritis, rheumatoid arthritis, scleroderma, and ‘‘other.’’ Ofthese conditions, osteoarthritis is reported to be causallylinked to overweight and obesity due to the wear and tearon joints caused by the additional weight [41,42]. Comparing

women with osteoarthritis as their primary disabling condi-tion to those with the remaining types of joint or connectivetissue diseases, we found no differences in the percentagewho were overweight or obese [c2 (df 5 2, N 5 251) 5

3.22, p 5 .20]; thus, the higher rates of overweight and obe-sity in those with joint and connective tissue disease do notappear to be accounted for simply by the higher likelihoodof obese women developing osteoarthritis.

To disentangle the relative influence of demographic anddisability characteristics, we conducted two linear regres-sion analyses with BMI as the continuous dependent vari-able. The first model included demographic covariates ofage, race, education, household income, and whether theparticipant was employed. Because age had a curvilinearassociation with the outcome variable, we categorized itinto three groups (!45, 45-64, and >65 years). House-hold income was classified as above or below poverty levelor as missing. This model yielded an R2 of 6.7% [F(11,431) 5 2.80, p 5 .0015]. The significant variables basedon the type III sums of squares were age group (!45 com-pared to 45-64) and race/ethnicity (black versus Hispanicand black versus non-Hispanic white).

To determine the association of BMI and disability be-yond the effect of demographics, we constructed a secondmodel that added the variables of duration of disability, dis-ability type, and physical functioning score on the SF-36(Table 3). This model yielded an R2 of 14.6%[F(18,424) 5

4.02, p ! .0001]. In other words, disability factorsaccounted for an additional almost 8% or more than doublethe variance in overweight and obesity are beyond demo-graphic factors. Significant variables in this model thatwere associated with excess weight included age (45-64years old), disability type (with joint and connective tissuediseases on the high end of BMI and MS on the low end),and SF-36 physical functioning score (more severe limita-tions were associated with higher BMI).

To summarize, problems with weight among women withphysical disabilities appear to be more common among thosewho are middle-aged, black or Hispanic, who have a joint orconnective tissue disease, and who have more extensive func-tional limitations. In the final analysis, however, disabilityfactors are more strongly associated with overweight andobesity than demographic factors other than age.

Association with secondary conditionsHaving examined demographic and disability-related cor-

relates of BMI, we next examined the relation betweenweight classification and self-reported health conditionsfrom the Health Conditions Checklist (see Table 4). Giventhe long list of items on the health conditions checklist(n 5 43), we adjusted the required p value to p < .001(.05 / 43) in order to minimize our Type I error rate. We thenexamined the relation between weight classification andwhether the participants reported ever having each of thehealth conditions listed. Weight classification was signifi-cantly related to whether or not the women had ever had

93Health Journal 1 (2008) 89e98

94 M.A. Nosek et al. / Disability and Health Journal 1 (2008) 89e98

diabetes [c2 (df 5 2; N 5 443) 5 41.81, p < .001] and bloodpressure problems [c2 (df 5 2; N 5 443) 5 24.21, p < .001].The percentages of women with diabetes who were normalweight, overweight, and obese were 8.1%, 31.1%, and60.9%, respectively, compared to 35.8%, 24.1%, and40.1% among those who did not have diabetes. The percent-ages of women with blood pressure problems who were nor-mal weight, overweight, and obese were 17.7%, 25.7%, and56.6%, respectively, compared to 36.1%, 27.8%, and 36.1%among those who did not have blood pressure problems.

Discussion

Prevalence of overweight and obesity

These findings indicate extremely high prevalence ofoverweight and obesity in women with physical disabilities.With three-quarters of the sample either overweight orobese and nearly 14% extremely obese, this sample far ex-ceeded rates found in the general population of women.

Associations with demographics and disability

The extremely high rate of obesity that we found isin part attributable to the disproportionately high

representation of minority women in this sample combinedwith the intercorrelation of low socioeconomic status andlimited physical activity. Women and individuals of low so-cioeconomic status within racial and ethnic minority popu-lations seem to be disproportionately at risk for overweightand obesity. Cultural factors influencing diet and exercisebehaviors have been shown to impact weight and over-weight in minority groups [43]. In the general U.S. popula-tion, 79.5% of non-Hispanic black women and 73.0% ofMexican-American women are overweight or obese com-pared to 57.6% of non-Hispanic white women [44]. Ouranalysis of excessive weight among minority women docu-mented an even greater gap, with 84.0% of black and83.8% of Hispanic women with disabilities overweight orobese compared to 56.7% of non-Hispanic white womenwith disabilities. Greater differences are found, however,in the examination of obesity alone; 47.6% of Hispanicand 41.4 % of non-Hispanic white women with disabilitiescompared to 39.8% of Mexican-American and 30.7% ofnon-Hispanic white women in the general U.S. population[44]. Interestingly, there was no difference in rates of obe-sity between black women with disabilities in our study

Table 3

Parameter Estimates for Linear Regression Model of Body Mass Index on

Demographic and Disability Variables

Parameter Estimate

Standard

error P value

Intercept 29.70 2.09 !.0001

Age (reference group is >65 y)

!45 0.90 1.53 .5601

45-64 2.58 1.23 .0370

Education (reference group is

college degree)

Less than high school 2.65 1.87 .1576

High school graduate 2.60 1.41 .0657

Technical school or some college 2.32 1.23 .0612

Income level (reference group is

above poverty)

Below poverty 0.27 1.15 .8114

Unknown 0.13 1.06 .9054

Working for pay 0.91 1.20 .4511

Race (reference group is non-Hispanic

white)

Black 1.11 1.08 .3021

Hispanic �0.94 1.34 .4807

Other 2.84 1.95 .1462

Duration of disability in months �0.004 0.003 .1718

Disability type (reference group is

Joint and connective tissue diseases)

Spinal cord injury �3.95 1.44 .0063

Stroke �4.57 1.46 .0018

Multiple sclerosis �8.46 1.62 !.0001

Polio 0.52 2.19 .8131

Other �0.87 1.28 .4985

SF36 Physical Functioning �0.05 0.02 .0055

Table 4

Association of Weight Category with Prevalence of Health Conditions

(N 5 443) (c2 Analysis)

% (n) Normal Overweight Obese

Pain* 83.8 (371) 23.7% 26.4% 49.9%

Fatigue 77.4 (343) 27.4% 25.4% 47.2%

Visual impairment 62.5 (277) 23.8% 28.2% 48.0%

Weakness 62.8 (277) 27.4% 24.2% 48.4%

Circulatory problems 60.1 (266) 23.3% 25.9% 50.8%

Sleep problems 59.8 (265) 23.4% 27.2% 49.4%

Spasticity 58.0 (257) 26.9% 24.5% 48.6%

Depression 56.9 (252) 25.0% 25.8% 49.2%

Blood pressure problemsy 56.2 (249) 17.7% 25.7% 56.6%

Memory problems 50.3 (223) 27.8% 25.6% 46.6%

Bowel problems 45.6 (202) 28.2% 23.8% 48.0%

Stomach problems 38.8 (172) 20.9% 27.3% 51.7%

Diabetesy 36.3 (161) 8.1% 31.1% 60.9%

Injuries 31.2 (138) 29.7% 22.5% 47.8%

Other bladder problems 29.0 (128) 29.7% 25.0% 45.3%

Urinary tract infection* 27.8 (123) 35.0% 22.0% 43.1%

Osteoporosis 25.5 (113) 28.3% 29.2% 42.5%

Hearing impairment 22.4 (99) 24.2% 23.2% 52.5%

Carpal-tunnel** 18.5 (82) 11.0% 28.1% 61.0%

Cardiovascular problems 18.2 (81) 17.3% 27.2% 55.6%

Yeast infection 17.8 (79) 27.9% 26.6% 45.6%

Contractures* 17.6 (78) 34.6% 32.1% 33.3%

Heart disease 16.3 (72) 15.3% 29.2% 55.6%

Respiratory infection* 15.6 (69) 23.2% 15.9% 60.9%

Anemia* 14.2 (63) 38.1% 17.5% 44.4%

Menstrual problems 11.3 (50) 26.0% 26.0% 48.0%

Sexual dysfunction 10.4 (46) 21.7% 30.4% 47.8%

Speech impairment 10.4 (46) 32.6% 17.4% 50.0%

Dysreflexia 9.7 (43) 34.9% 20.9% 44.2%

Scoliosis* 9.7 (43) 44.2% 16.3% 39.5%

* p ! .05.

** p ! .01.y p ! .001.

95M.A. Nosek et al. / Disability and Health Journal 1 (2008) 89e98

(52.0%) and black women in the general U.S. population(51.1%).

In further pursuit of an answer to our research questionabout the role of demographic and disability factors, wefound that middle-aged women with physical disabilitieswere more likely to be overweight or obese (78.7%) com-pared to women aged 18 to 44 years (62.2%) or 65 yearsand older (67.2%). Higher rates are also found in middle-aged women in general (68.3%) compared to youngerwomen in general (55.3%), but rates are virtually the samefor middle-aged and older women in general (67.9%). It isunderstandable that younger women with disabilities wouldsimilarly have a lower prevalence of overweight thanmiddle-aged women with disabilities, especially becausethe mobility limitations that are associated with weight gaintend to occur later in life. The significantly lower rates inolder versus middle-aged women with disabilities, how-ever, can be interpreted various ways. The rigors of aging,including decreased muscle mass, may have an exaggeratedeffect on women with long-term physical disability. A morelikely and, unfortunately, more ominous interpretation isthat excess weight carries a greater risk for mortality inwomen who have physical disabilities. Further studies arerequired to examine survival rates for obese women withphysical disabilities and to determine the extent to whichexcess weight versus disability and other conditions associ-ated with disability contribute to mortality.

Perhaps our most meaningful finding is that disabilityfactors are more strongly associated with overweight andobesity than demographic factors other than age, but in-cluding race. Although disability type has rarely surfacedas a significant variable in previous health promotion re-search by the authors, some interesting differences emergedfrom this study. The finding that women with MS are morelikely to be of normal weight is consistent with the smallliterature available [45]. With regard to the higher percent-age of women with joint and connective tissue disorders be-ing classified as overweight or obese, there is a causal linkbetween joint and connective tissue disorders and over-weight via reduced physical activity. The final regressionmodel indicated a significant association between over-weight/obesity and severity of functional limitations, whichis consistent with previous research [46].

Our findings indicate a profile of overweight womenwith disabilities that is similar to overweight women inthe general population [44,47]: middle age, nonwhite (pri-marily black) or Hispanic, and low income. Disparitiesbased on age, race/ethnicity, and income are further aug-mented by disability, with women who have joint and con-nective tissue disorders and those with more extensivefunctional limitations being at the highest risk for excessweight. It would be a valuable contribution to the under-standing of this health disparity to sample women withand without disabilities who are matched on BMI and ex-amine factors related to race/ethnicity, patterns of physicalactivity, and nutrition behaviors as well as measures of

body composition and biometric markers of metabolic riskfactors to determine the amount of variance that is attribut-able to race/ethnicity versus disability.

Associations with secondary conditions

Our third research question asked about the relation ofother secondary conditions to overweight and obesity inwomen with disabilities. We found that overweight andobesity in this population are associated with a number ofserious health problems, including diabetes and hyperten-sion, conditions that can lead to increased disability andpremature mortality. This is consistent with what one wouldexpect to find in a sample of women from general popula-tion. The most notable aspect of these findings, however, isthe extremely disproportional occurrence of these condi-tions in women with physical disabilities. Women in oursample reported having diabetes 4 times as often as womenin general (36.3% versus 8.9% [48]) and hypertensionnearly twice as often (56.2% versus 30.9% [49]). Whethertaken alone or viewed as secondary to a primary disablingcondition, these statistics reflect serious health disparitiesexperienced by women with disabilities. Taken together,obesity, diabetes, and high blood pressure constitute an ex-tremely high-risk profile for cardiovascular disease, yetvery little attention has been paid to what would appearto be a problem of epidemic proportions in this subpopula-tion of women. Although some attention has been paid toheart disease in women with spinal cord injury [50], themajority of literature on heart disease in adults with disabil-ities focuses on men with SCI. The examination of heartdisease in other types of disabilities is primarily limitedto those conditions that are associated with cardiac dys-function, such as rheumatoid arthritis and myotonic dystro-phy. Research is urgently called for on the prevalence of alltypes of cardiovascular disease in women with the fullrange of physical disabilities with a specific focus on bio-logic and lifestyle risk factors and interventions for preven-tion and management.

Limitations of the study

The limitations of this study are inherent in the charac-teristics of this sample and the means of collecting data.This was a convenience sample that was overrepresentativeof minority women compared to the general population ofwomen with physical disabilities. Based on literature thatdocuments a higher prevalence of overweight and obesityin minority women, this could lead to an overestimationof the problem. Among other demographic characteristics,this sample of women had higher levels of education thanwomen with physical disabilities in general. However, theywere very similar in age, poverty status, and employmentstatus [4].

The second major limitation of this study lies in the self-reported data. The accuracy of measuring body mass index

96 M.A. Nosek et al. / Disability and Health Journal 1 (2008) 89e98

based on self-reported data versus anthropomorphic mea-sures has been tested and found to yield consistent under-estimation of obesity [51,52]. The tendency is tounderestimate weight and overestimate height. Becausemany women with physical disabilities have no access toscales or accurate means of measuring their weight [53],self-reported estimates of weight in this population maybe even less accurate than those reported by women with-out disabilities.

With less than two thirds of the women reporting theirhousehold income, we faced limitations in analyzing the re-lation of socioeconomic status and weight. Also, becausethis study used a cross-sectional design, we cannot makeany statements that imply causality. In other words, wedo not know whether we are looking at obesity in the con-text of disability or disability in the context of obesity.

Validity of body mass index

Loss of lean muscle mass that characterizes most dis-abilities makes determining estimates of overweight andobesity particularly problematic when using calculationsof BMI [32,34,54-56]. Some investigators question the val-idity of using the BMI for people with SCI; however, theirstudies have been predominantly on men. Buchholz andcolleagues [55] found that it is an insensitive marker ofobesity, explains less of the variance in measured percentfat mass than in people without disabilities, and is inconsis-tently related to coronary heart disease risk factors. Theystate that this may be due to potential measurement errorand to the inability of BMI to distinguish between fat andfat-free mass or to measure body fat distribution. Joneset al. [56] compared BMI to dual-energy x-ray absorptiom-etry measures of total and regional lean tissue mass and fatmass in a small sample of men with SCI. They concludedthat many people with SCI do not appear to be obese, yetthey carry large amounts of fat tissue. They warn thatBMI may underestimate body fat in men with SCI. Someinvestigators prefer measures of waist circumference [55]and bioelectrical impedance analysis (BIA) to circumventthis problem [57,58]. Other investigators question the valid-ity of BMI measures in Asian women [59] and postmeno-pausal women [60].

The problem with focusing on physical activity

Almost without exception, guidelines and interventionsfor weight management require a balance of improvednutritional behaviors with an increase in physical activity[61-64]. Women with severe functional impairments dueto disability are seriously limited in the amount of physicalactivity they can pursue. For those who have only wheel-chair mobility and limited use of their arms, achievementof an aerobic effect is very difficult if not impossible. In-deed, certain types of strengthening exercises are contrain-dicated for persons with muscle wasting disorders,

including postpoliomyelitis syndrome [65] and inflamma-tory myopathies [66]. Traditional techniques for determin-ing level of physical activity, such as pedometers oraccelerometers, have very limited usefulness. The popula-tion of women with physical disabilities faces numerouspersonal and environmental barriers to increasing physicalactivity and has been excluded from examinations of othermeans of weight loss.

The need for weight management interventions

If a limitation of this study is, therefore, most likely anunderestimation of obesity due to self-reported data or theinsensitivity of BMI to abnormal distribution of adiposity,then our statement about the severity of the problem ofobesity in women with physical disabilities would haveincreased importance. The magnitude of this problemmakes the absence of tested and disseminated interventionsfor weight management with a focus on the special needs ofthis population even more serious. Although several studieshave developed and tested psychoeducational interventionsdesigned to improve health behaviors [67-72], particularlyphysical activity [73], with a focus on women and disabilityrelated issues, such interventions have not become gener-ally available to women with disabilities living in the com-munity at large. Our findings emphasize the need foreffective weight management interventions that focus onwomen with disabilities, particularly minority womenwho are generally less likely to participate in weight man-agement programs, and that offer a balance of informationand action planning related to nutritional behaviors as wellas physical activity.

Acknowledgments

This work was supported by the Centers for DiseaseControl and Prevention (grant RO4/CCR618805).

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