Short Communication

Relationship between Body Weight Gain and Significant Knee, Hip, and Back Pain in Older Americans
Ross E. Andersen,* Carlos J. Crespo, Susan J. Bartlett, Joan M. Bathon, and Kevin R. Fontaine
Abstract ANDERSEN, ROSS E., CARLOS J. CRESPO, SUSAN J. BARTLETT, JOAN M. BATHON, AND KEVIN R. FONTAINE. Relationship between body weight gain and significant knee, hip, and back pain in older Americans. Obes Res. 2003;11:1159-1162. Objective: To examine the association between BMI (kilograms per meter squared) and reports of significant knee, hip, and back pain using data from a nationally representative sample of U.S. adults 60 years or older. Research Methods and Procedures: Population-based survey data from the Third National Health and Nutrition Examination Survey, involving 5724 adults 60 years or older, were used. BMI, calculated from measured weight (kilograms) and height (meters squared), was used to categorize participants into six BMI-defined groups: underweight (18.5), desirable weight (18.5 to 24.9), overweight (25 to 29.9), obese class I (30 to 34.9), obese class II (35 to 39.9), and obese class III (40). The presence of significant knee, hip, and back pain in the groups was studied. Results: The overall prevalences of knee, hip, and back pain were 21%, 14%, and 22%, respectively. Prevalence estimates for knee (underweight 12.1% to obesity class III 55.7%), hip (underweight 10.4% to obesity class III 23.3%), and back (underweight 20.2% to obesity class III 26.1%) pain increased with increased BMI. Sex-, race-, and agespecific pain prevalence estimates also generally increased at increased levels of BMI. Discussion: Among U.S. adults 60 years or older, the prevalence of significant knee, hip, and back pain increases with increased levels of BMI. Key words: BMI, pain, Third National Health and Nutrition Examination Survey

Introduction
The prevalence of both obesity and its associated health problems continues to increase dramatically in the U.S. (1). It is estimated that between 1991 and 1998, the prevalence of obesity among adults 60 to 69 years old and over 70 years increased by 44.9% and 28.6%, respectively (2). Musculoskeletal pain of the knee, hip, and back are among the most frequently occurring and debilitating chronic medical conditions affecting the U.S. population (3). Overall, painful disorders of the musculoskeletal system are the leading cause of work-related disability among men and women 16 to 72 years old and the leading cause of disability among Americans over the age of 65 (4,5). The purpose of this study, therefore, was to examine the relationship between BMI (kilograms per meter squared) and reports of significant knee and hip pain, using data from a nationally representative sample of U.S. adults 60 years or older.

Research Methods and Procedures

The Third National Health and Nutrition Examination Survey (NHANES III)1 was conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics. NHANES combines a home interview with health tests that are done in a mobile examination center. The plan of operation of NHANES III has been described in detail elsewhere (6,7). In brief, this survey collected information about health and diet in a nationally representative sample

Received for review March 11, 2003. Accepted in final form August 18, 2003. *Divisions of Geriatric Medicine and Gerontology and Rheumatology, Johns Hopkins School of Medicine, Baltimore, Maryland and School of Medicine and Biomedical Science, State University at Buffalo, Buffalo, New York. Address correspondence to Dr. Ross Andersen, Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224. E-mail: andersen@jhmi.edu Copyright 2003 NAASO

1 Nonstandard abbreviation: NHANES III, Third National Health and Nutrition Examination Survey.

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of the civilian noninstitutionalized U.S. population. Another important purpose of this survey was to estimate the prevalence of a variety of health conditions and risk factors. Operationally, NHANES III represented a 6-year study, involving two 3-year phases conducted from 1988 to 1994. NHANES III collected its data in two 3-year phases because each phase was considered nationally representative so that interim analyses could be done when Phase I was completed. The results presented herein are derived from both phases of the NHANES III data collection. Mexican Americans, non-Hispanic blacks, and older adults were oversampled in NHANES III to ensure weighted, unbiased estimates from these particular groups. Survey interviews took place in the participants homes, followed 2 to 3 weeks later by a detailed clinical/physical examination conducted in a mobile examination center. Interviews and examinations were conducted on 5724 adults 60 years or older. Interviewers were well experienced, and many were of Hispanic origin or fluent in both English and Spanish. All staff underwent yearly training sessions to ensure quality control. Study Variables Self-reported race and ethnicity were used to classify participants as non-Hispanic white, non-Hispanic black, or Mexican American (i.e., persons of Mexican origin living in the U.S.). Age was defined as the age in years at the time of the household interview and, for analytic purposes, categorized into three groups (60 to 69 years, 70 to 79 years, and 80 years). During the medical examination, height was measured using a stadiometer, and weight was measured on a balance beam scale. Height and weight data were then used to calculate BMI. BMI is largely independent of height (r 0.03), strongly related to weight (r 0.86), and a reasonable measure of adiposity (8). Based on the weight classifications developed by the National Heart Lung and Blood Institute (9), we grouped participants according to six BMIdefined categories (18.5, underweight; 18.5 to 24.9, desirable weight; 25 to 29.9, overweight; 30 to 34.9, obesity class I; 35 to 39.9, obesity class II; and 40, obesity class III). Participants were asked three separate questions to assess significant knee, hip, and back pain (i.e., whether they had experienced significant knee pain on most days over the preceding 6 weeks, whether they had experienced significant hip pain on most days over the preceding 6 weeks, and whether they had experienced significant back pain on most days for at least 1 month and have had this pain within the past 12 months). The pain-related questions asked in NHANES III are well-validated (10). Statistical Analysis We performed the statistical analyses using SAS and STATA statistical software (SAS Institute Inc., Cary, NC).
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For each survey, we calculated sample weights that took account of the unequal selection probabilities resulting from both the cluster design and the planned over-sampling of certain subgroups. Prevalence estimates were derived and are presented for the sex, race, and age categories as described above. All analyses reported have incorporated sampling weights.

Results
The overall prevalences of significant knee, hip, and back pain were 21%, 14%, and 22%, respectively. Table 1 presents the sex-, race-, and age-specific prevalence estimates of older U.S. adults reporting significant knee, hip, or back pain in each of the six BMI-defined weight classifications (see Table 1). For all three sites of pain, prevalence estimates increased with increased BMI. The relation between BMI and pain prevalence was stronger for knee pain (underweight 12.1% to obesity class III 55.7%) than for either hip (underweight 10.4% to obesity class III 23.3%) or back pain (underweight 20.2% to obesity class III 26.1%). In general, the sex-, race-, and age-specific pain prevalence estimates also increased at increased levels of BMI. Exceptions included: for knee pain, the estimates for men, non-Hispanic blacks, and Mexican Americans; for hip pain, the estimates for women, non-Hispanic blacks, and those at 80 years of age; and for back pain, the estimates for women, non-Hispanic blacks, and those at 80 years of age. In these subgroups, we observed roughly J- or Ushaped relations between BMI and pain prevalence.

Discussion
These cross-sectional population-based survey data indicate that, among adults 60 years and older, the prevalence of significant knee, hip, and back pain increases markedly with increased BMI. The estimated prevalence of knee pain increased by 44% over the range of BMI (i.e., from 12% for underweight participants to 56% for obesity class III participants), and a similar pattern, though not as pronounced, occurred with regard to the prevalences of hip and back pain. This general pattern of findings remained even when we calculated the pain prevalence estimates along the six BMIcategories according to sex-, race-, and age-specific subgroups. The few exceptions to this pattern tended to show a J-or U-shaped relationship between pain prevalence and BMI, that is, higher pain prevalence estimates at the lower and higher BMI categories. The reasons for the nonlinear pattern are unknown but may relate to errors introduced by the self-reporting of pain or sampling variation. Perhaps, however, for some reason, (e.g., occupational knee demands, underlying illness), there is a true difference in the association within the lower and upper BMI categories for

Table 1. Prevalence of knee, hip, and back pain in relation to BMI (kilograms per meter squared) category and according to selected demographic characteristics among U.S. adults 60 years or greater
BMI-defined categories All 12.1 (5.6 to 18.6) 26.9 (9.0 to 44.7) 6.0 (1.2 to 10.7) 9.2 (2.5 to 15.9) 23.1 (6.3 to 39.9) 35.8 (14.8 to 56.7) 7.8 14.0 16.2 10.4 5.4 (.42 to 11.2) 12.5 (5.4 to 19.6) 9.4 (6.6 to 12.1) 14.3 (11.8 to 16.8) 12.6 (10.4 to 14.9) 11.4 (6.9 to 15.8) 16.5 (9.9 to 23.1) 11.7 11.2 16.2 20.9 20.0 (15.8 to 24.2) 21.6 (18.2 to 24.9) 21.0 (18.0 to 23.9) 20.6 (15.1 to 26.0) 21.3 (16.0 to 26.6) 21.8 (17.6 to 25.9) 18.8 (13.6 to 23.9) 23.3 (17.9 to 28.7) (7.3 to 16.2) (7.7 to 14.7) (12.4 to 19.9) (18.3 to 23.6) 11.7 16.7 15.3 21.3 13.3 (11.4 to 15.2) 18.0 (13.1 to 22.8) 11.6 (6.3 to 16.9) (9.1 to 14.3) (12.9 to 20.6) (10.7 to 19.8) (18.7 to 23.8) 19.2 (16.2 to 22.1) 23.3 (19.2 to 27.5) 20.7 (17.9 to 23.5) 25.2 (20.1 to 30.3) 19.2 (15.3 to 23.0) 19.0 (14.9 to 23.0) 24.2 (20.2 to 28.2) 22.5 (17.9 to 27.2) 13.0 (10.5 to 15.5) 14.9 (12.2 to 17.5) 8.2 (2.2 to 14.2) 13.3 (1.4 to 25.1) 7.5 (2.3 to 17.5) 5.8 7.2 19.7 20.2 12.6 (2.3 to 23.0) 23.3 (12.6 to 34.0) 17.9 (8.2 to 27.6) 27.2 (13.8 to 40.6) 17.5 (2.7 to 32.3) 11.6 (2.0 to 25.2) 21.7 (5.7 to 37.7) 30.6 (18.4 to 42.8) (2.7 to 14.4) (2.0 to 16.5) (7.6 to 31.9) (12.6 to 27.8) (2.6 to 18.3) (1.1 to 29.2) (6.0 to 26.4) (5.2 to 15.6) 12.7 14.3 23.0 12.4 (9.2 to 16.2) (10.7 to 17.8) (16.7 to 29.3) (10.3 to 14.4) 17.4 23.8 28.6 13.9 (14.0 (17.9 (23.3 (12.2 to to to to 20.9) 27.9) 33.8) 15.7) 23.5 29.9 43.1 17.8 (18.3 (23.1 (32.6 (14.1 to to to to 27.8) 36.7) 53.5) 21.5) 15.2 (9.2 to 21.2) 19.8 (13.5 to 26.1) 18.3 (13.8 to 22.8) 12.4 (7.2 to 17.6) 24.8 (16.3 to 33.3) 17.5 20.4 9.9 22.3 (12.5 to 22.6) (14.8 to 26.0) (4.8 to 12.9) (18.7 to 25.9) 19.2 (14.1 to 24.2) 24.7 (19.3 to 30.1) 22.6 (18.5 to 26.6) 19.0 (14.0 to 24.0) 24.7 (14.6 to 34.8) 20.4 (15.3 to 25.5) 23.9 (17.1 to 30.8) 27.9 (17.3 to 38.5) 35.1 38.2 35.8 17.8 14.9 (12.9 to 17.0) 20.3 (14.8 to 25.6) 18.6 (14.5 to 22.6) 20.8 (17.7 to 23.9) 28.9 (24.7 to 33.1) 20.7 (15.4 to 25.9) 28.3 (23.6 to 33.0) 22.9 (15.9 to 29.9) 31.5 (23.8 to 39.1) 12.5 (9.2 to 15.8) 16.9 (14.4 to 19.5) 18.5 (15.3 to 21.6) 24.1 (20.0 to 28.2) 26.2 (19.2 to 33.1) 28.5 (24.0 to 33.0) 25.2 (13.5 to 36.8) 40.8 (31.6 to 49.9) 36.9 (28.0 to 45.7) 42.5 (30.3 to 54.5) 37.9 (23.8 to 51.9) (25.2 to 45.0) (24.5 to 51.9) (8.0 to 63.6) (11.0 to 24.6) 7.3 (1.0 to 13.5) 22.3 (13.9 to 30.6) 19.8 (11.9 to 27.7) 12.5 (3.1 to 21.9) 10.8 (3.1 to 18.6) 14.7 22.3 23.1 24.4 (7.0 to 22.4) (9.4 to 35.3) (4.5 to 41.6) (18.3 to 30.5) 9.7 (.70 to 18.8) 30.5 (21.5 to 39.5) 23.6 (16.5 to 30.8) 29.4 (16.1 to 42.7) 30.7 (18.0 to 43.3) 23.0 (14.3 to 31.7) 26.9 (15.2 to 38.5) 24.0 (4.3 to 43.7) 15.2 (13.3 to 17.1) 21.3 (18.5 to 24.1) 27.5 (23.6 to 31.4) 36.2 (28.2 to 44.1) <18.5 (Underweight) 18.5 to 24.9 (Desirable weight) 25 to 29.9 (Overweight) 30 to 34.9 (Obesity class I) 35 to 39.9 (Obesity class II) >40 (Obesity class III) 55.7 (41.1 to 70.2) 43.5 (14.9 to 72.0) 57.9 (40.7 to 75.0) 53.3 (33.8 to 72.7) 66.0 (49.6 to 82.4) * 48.2 (30.3 to 66.2) 67.1 (47.7 to 85.5) * 23.3 (12.8 to 33.7) 22.5 (1.4 to 46.5) 23.4 (12.5 to 34.4) 24.8 (12.0 to 37.6) 15.3 (3.3 to 27.2) * 19.3 29.2 50.3 26.1 (7.3 to 31.3) (10.6 to 47.9) (.85 to 100) (15.0 to 37.1) 31.2 (1.9 to 64.4) 25.1 (14.1 to 36.2) 22.4 (8.3 to 36.6) 34.2 (22.5 to 45.9) * 26.8 (14.6 to 38.9) 24.7 (9.1 to 40.4) 24.8 (18.7 to 68)

Site of pain

Demographic characteristics

21.4 (19.6 to 23.2)

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18.4 (16.4 to 20.4) 23.6 (21.4 to 25.9)

21.0 (19.0 to 23.0) 27.8 (24.7 to 30.8) 24.3 (21.0 to 27.6) (16.7 (19.8 (22.7 (13.2 to to to to 20.8) 25.4) 32.2) 15.6)

18.8 22.6 27.5 14.4

12.0 (10.3 to 13.7) 16.2 (14.5 to 17.8)

14.3 (13.0 to 15.7) 14.3 (11.8 to 16.9) 15.5 (12.6 to 18.4) (11.1 (13.7 (12.8 (20.1 to to to to 15.1) 17.6) 18.5) 23.1)

13.1 15.6 15.7 21.6

19.1 (16.7 to 21.5) 23.5 (21.4 to 25.5)

21.2 (19.6 to 23.0) 23.5 (20.3 to 26.7) 21.8 (17.8 to 25.7)

Knee pain: % (95% CI) Sex Men Women Race Non-Hispanic white Non-Hispanic black Mexican-American Age 60 to 69 70 to 79 80 Hip pain: % (95% CI) Sex Men Women Race Non-Hispanic white Non-Hispanic black Mexican-American Age 60 to 69 70 to 79 80 Back pain: %, (95% CI) Sex Men Women Race Non-Hispanic white Non-Hispanic black Mexican-American Age 60 to 69 70 to 79 80

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20.4 (17.8 to 23.1) 22.3 (19.6 to 25.0) 24.0 (20.5 to 27.3)

* Sample size is too small (N 30) to report valid estimates. CI, confidence interval.

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certain subgroups. Understanding the reasons for these differences requires further investigation. The observed BMI-pain associations are consistent with what has been observed among persons with obesity seeking weight loss using university-based treatments (11,12) and in the small body of work (e.g., 13,14) suggesting that weight reduction can reduce reports of musculoskeletal pain. It is important to note that self-reports of pain in NHANES III were not verified objectively. Moreover, the cross-sectional nature of the NHANES III does not allow us to test causal inferences (i.e., determine whether BMI preceded the pain or vice versa) nor determine whether the association between weight and pain is mediated by conditions such as osteoarthritis or diabetic neuropathy. Nonetheless, one could speculate that, given the established link between obesity and osteoarthritis of the knee and hip (15,16) and between obesity and back pain (17), maintaining a healthy weight may reduce the prevalence of knee, hip, and back pain in older adults. However, whether intentional weight loss would reduce the prevalence of reports of significant knee, hip, and back pain in older adults remains uncertain.

Acknowledgments
R.E.A.s work is supported by Grant RO1 DK 5390701A1 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). S.J.B. has a K-23 award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and K.R.F. is supported, in part, by grants from the Arthritis Foundation and the Blaustein Pain Research Fund.
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