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ts incorrectly identified sudden chest pain or discom

(which is a warning symptom of a heart attack) as a
ning symptom of stroke (Table 1).
wareness of individual stroke warning symptoms varied
acelethnicity, sex, and level of education. Whites,
nen, and persons at higher education levels were more
y to be aware of individual stroke warning symptoms

more likely to call 9-1-1 if they thought that someone
: having a heart attack or stroke than were blacks,
panics, men, and persons at lower levels of education
ble 1).
wareness of individual stroke warning symptoms also
ed by area. Respondent awareness ranged from 87.2%
uisiana) to 96.4% (Minnesota) for sudden numbness
veakness of the face, arm, or leg, especially on one side;
2 79.0% (Louisiana) to 92.9% (West Virginia) for sud-

den confusion or trouble speaking; from 77.1% (Louisiana) to 91.4% (Minnesota) for sudden trouble walking, dizziness, or loss of balance; from 62.0% (Oklahoma) to 76.5% (Minnesota) for sudden trouble seeing in one or both eyes; and from 51.8% (DC) to 68.8% (Minnesota) for severe headache with no known cause. The percentage of respondents who reported that they would call 9-1-1 if they thought someone was having a heart attack or stroke ranged from 77.7% (Mississippi) to 89.0% (Minnesota) (Table 1).

All five stroke warning symptoms were identified by 43.6% of respondents; 18.6% were aware of all stroke warning symptoms and knew that sudden chest pain is not a stroke warning sign; 38.1% were aware of all stroke warning symptoms and would first call 9-1-1 if they thought that someone was having a heart attack or stroke, and 16.4%

LE 1. Age-adjusted percentage of respondents who recognized stroke warning symptoms, misidentified an incorrect symptom,* said they would first call 9-1-1 if someone appeared to be having a stroke or heart attack, by symptom, selected characteristics, area Behavioral Risk Factor Surveillance System, 13 states and the District of Columbia (DC), 2005 Sudden

Would first numbness or

call 9-1-1 weakness

Sudden trouble ľ

if someone of face,

walking,
A severe

was possibly
Sudden
arm, or leg, Sudden trouble dizziness,

headache Sudden chest

having confusion or especially seeing in one

or loss
with no

pain or

a stroke or acteristic/ No. of trouble speaking

on one side
or both eyes

of balance
known cause
discomfort

heart attack
%
respondents (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)

71,994 86.5 (86.0–87.0) 92.6 (92.2–93.0) 68.8 (68.2–69.4) 83.4 (82.9–83.9) 60.4 (59.8–61.1) 39.5 (38.8–40.1) 85.9 (85.4–86.4) Ethnicity

57,761 90.1 (89.6–90.5) 94.9 (94.5–95.3) 72.2 (71.5–72.8) 86.2 (85.7–86.7) 61.9 (59.9–63.2) 37.3 (36.6–38.0) 86.8 (86.3–87.3) ik

7,673 79.0 (77.4–80.5) 88.0 (86.6–89.2) 58.8 (56.6–60.3) 75.8 (74.1-77.5) 55.8 (53.8–57.7) 47.9 (40.6–49.8) 83.7 (82.3–85.1) janic

2,548 67.8 (64.5–70.9) 79.2 (76.1-81.9) 53.8 (50.8–56.9) 70.0 (66.9–70.3) 57.9 (54.7-61.1) 43.6 (40.5–46.8) 83.1 (80.3–85.6) 3,351 76.0 (72.4–79.3) 87.1 (84.1-89.5) 61.3 (57.7-64.9) 76.4 (73.0–79.5) 53.1 (49.3–56.8) 46.2 (42.5–50.0) 83.1 (79.9–85.9)

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3,197 87.6 (85.7-89.3) 95.3 (94.4–96.0) 70.0 (67.8–72.1)

3,743 82.0 (80.0–83.8) 90.0 (88.5-91.3) 62.8 (60.7–64.9) da

8,190 84.0 (82.6–85.3) 91.1 (89.9–92.1) 67.6 (66.0–69.2)

5,051 90.3 (89.1–91.3) 94.6 (93.7–95.3) 71.1 (69.5–72.7) siana

2,936 79.0 (77.0-80.8) 87.2 (85.7-88.6) 62.9 (60.7–65.0) ie

3,960 87.8 (86.3–89.2) 93.2 (91.9–94.2) 67.9 (66.0-69.8) nesota

2.829 91.7 (90.2–92.9) 96.4 (95.5–97.1) 76.5 (74.5–78.4) sissippi 4,439 87.1 (85.8–88.3) 93.0 (92.0–93.9) 65.2 (63.3-67.0) souri

5,164 86.8 (85.1-88.4) 93.6 (91.7-95.2) 66.1 (64.0_68.2) tana

4,983 89.0 (87.5–90.3) 94.7 (93.6–95.6) 70.7 (68.8–72.5) thoma

13,707 83.7 (82.4–85.0) 90.2 (89.1-91.3) 62.0 (60.5–63.4) nessee

4,749 86.1 (84.4–87.5) 90.6 (89.2–91.9) 72.3 (70.4–74.1) inia

5,493 88.4 (87.0–89.6) 94.2 (93.1-95.0) 69.3 (67.5–71.1) it Virginia 3,553 92.9 (91.7–93.9) 95.6 (94.7–96.3) 75.1 (73.4–76.7) den chest pain or discomfort, which is a symptom for heart attack but not for stroke. fidence interval.

81.8 (80.0–83.5) 79.1 (77.1-81.9) 82.0 (80.6–83.3) 88.7 (87.5–89.4) 77.1 (75.2–79.0) 84.6 (83.2–86.0) 91.4 (90.2–92.6) 80.3 (78.8–81.8) 83.1 (81.4–84.8) 87.6 (86.2–88.9) 79.4 (78.1-80.7) 80.8 (79.0–82.5) 84.8 (83.4–86.1) 89.4 (88.2–90.5)

60.8 (58.5–63.0) 51.8 (49.6–53.9) 60.3 (58.6–61.9) 61.7 (60.0-63.4) 60.0 (57.8–62.1) 54.6 (52.6–56.6) 68.8 (66.6–70.8) 59.9 (58.0–61.8) 53.6 (51.4–55.8) 57.8 (55.8–59.8) 50.9 (49.3–52.4) 64.5 (62.4–66.6) 60.7 (58.8–62.6) 67.6 (65.7-69.5)

35.8 (33.6–38.1) 39.9 (37.7-42.1) 40.8 (39.2-42.5) 38.0 (36.4–39.7) 44.6 (42.4–46.8) 36.3 (34.4-38.3) 37.0 (34.8–39.2) 38.1 (36.2-40.0) 33.9 (31.8–36.1) 34.6 (32.7–36.6) 34.7 (33.3–36.1) 49.3 (47.2–51.5) 36.9 (35.0–38.8) 46.5 (44.5–48.5)

86.2 (84.4–87.9) 86.4 (84.8–87.9) 87.0 (85.7–88.2) 86.9 (85.6–88.0) 80.4 (78.5–82.1) 88.2 (86.8–89.5) 89.0 (87.6–90.3) 77.7 (76.0–79.3) 85.9 (84.4–87.2) 83.8 (82.1-85.3) 80.6 (79.4–81.8) 87.1 (85.5–88.4) 87.8 (86.5–89.0) 85.4 (84.0–86.7)

were aware of all five stroke warning symptoms, knew that sudden chest pain is not a stroke warning symptom, and would call 9-1-1 if they thought that someone was having a heart attack or stroke (Table 2). Awareness of all five stroke warning symptoms and calling 9-1-1 was higher among whites (41.3%), women (41.5%), and persons at higher education levels (47.6% for persons with a college degree or more) than among blacks and Hispanics (29.5% and 26.8%, respectively), men (34.5%), and persons at lower education levels (22.5% for those who had not received a high school diploma). Among states, the same measure ranged from 27.9% (Oklahoma) to 49.7% (Minnesota).

Reported by: ) Fang, MD, NL Keenan, PhD, C Ayala, PhD. 50
MD, PhD, R Merritt, MA, Div for Heart Disease and Stroke Preces
National Center for Chronic Disease Prevention and Health Proms
CH Denny, PhD, Div of Birth Defects and Developmental Disabi
National Center on Birth Defects and Developmental Disabilities

. Editorial Note: Immediate emergency transportation to hospital to receive timely urgent care can reduce disabil and even death associated with stroke. The American Som Association and National Stroke Association are work

1 with state and local health departments to increase pub! recognition of stroke warning symptoms and 9-1-1 ca that prioritize these symptoms as “possible stroke." 1:

(8.0-115

(6.0-8

TABLE 2. Age-adjusted percentage of respondents who recognized five correct stroke warning symptoms, identified one incorrec symptom,* and said they would first call 9-1-1 if someone appeared to be having a stroke or heart attack, by selected characteristes and area - Behavioral Risk Factor Surveillance System, 13 states and the District of Columbia (DC), 2005

All five correct

symptoms All five correct

one incorrect All symptoms and All five correct

symptom, five correct one incorrect symptoms and

and would Characteristic/

No. of
symptoms

symptom
would call 9-1-1

first call 9-1-1 Area Respondents % (95% CIS)

% (95% CI)
% (95% CI)

%

(95% C Total 71,994 43.6 (42.9–44.2)

18.6 (18.1–19.1)
38.1 (37.5–38.7)

16.4

(16.0–169 Race/Ethnicity White 57,761 46.9 (46.2-47.6)

21.1 (20.6-21.7)
41.3 (40.7–42.0)

18.7 (18.2-93 Black 7,673 33.9 (32.2–35.7)

10.2 (9.1–11.4)
29.5 (27.8–31.2)

8.8

(7.8-99 Hispanic

2,548
30.1 (27.4–34.9)
10.7 (9.1-12.6)
26.8 (24.2-29.6)

9.5 Other

3,351
34.8 (31.4–38.4)
12.0 (9.9–14.4)
28.7 (25.6–32.0)

10.2 (8.3-26 Sex Men

27,163
40.2 (39.2-41.2)
17.3 (16.6–18.1)
34.5 (33.5-35.4)

15.0 (14.3–159 Women

44,831
46.4 (45.7-47.2)
19.7 (19.1-20.3)
41.5 (40.7-42.2)

17.7 (17.1-18.3 Education Less than high school diploma 8,744 26.0 (24.3–27.8)

7.7 (6.7-8.9)
22.5 (20.9-24.3)

6.9 High school diploma 23,728

36.4 (35.3–37.5)
12.6 (12.6-13.3)
31.8 (30.7-32.8)

11.1 (10.5-113 Some college 18,505 47.7 (46.5-48.9)

20.1 (19.2-21.1)
41.8 (40.6–43.0)

17.9 (17.0–188 College degree or more 20,839 54.0 (52.9–55.1)

27.4 (26.4-28.4)
47.6 (46.5–48.8)

24.1 (23.2-251 Area Alabama

3,197
42.0 (39.9-42.2)
19.5 (17.9–21.3)
37.1 (35.0–39.2)

17.0 (15.5-187 DC 3,743 34.8 (32.9–36.7)

15.9 (14.6–17.4)
30.5 (28.7–32.4)

13.7 (12.5-151 Florida 8,190 41.8 (40.2-43.3)

18.7 (17.5–19.9)
37.4 (35.9–38.9)

16.9 (15.8-180 lowa

5,051
47.2 (45.5-48.8)
20.7 (19.4-22.1)
41.3 (39.6–42.9)

18.6 (17.4–199 Louisiana 2,936 39.1 (37.0–41.2)

13.7 (12.4-15.3)
32.1 (30.1-34.1)

11.5 (10.2-12: Maine

3,960
40.2 (38.3–42.1)
18.2 (16.8–19.7)
36.2 (34.4–38.1)

16.6 (15.2-18." Minnesota

2,829
55.7 (53.7-57.9)
25.5 (23.6–27.4)
49.7 (47.5–52.0)

22.9 (21.1-246 Mississippi

4,439
40.4 (38.6–42.3)
15.5 (14.2–16.8)
31.6 (29.9–33.3)

12.2 (11.1-135 Missouri 5,164 39.1 (37.1-41.1)

18.2 (16.7-19.8)
34.1 (32.1-36.1)

15.8 (14.4-17 Montana 4,983 43.1 (41.2–44.9)

21.1 (19.6-22.7)
36.6 (34.8–38.4)

18.4 (17.0–198 Oklahoma 13,707 34.4 (33.1-35.8)

14.3 (13.3–15.4)
27.9 (26.6–29.1)

11.8 (10.9-128 Tennessee 4,749 48.4 (46.4-50.5)

15.4 (14.0–16.9)
43.6 (41.6-45.7)

13.9 (12.6–153 Virginia

5,493
43.5 (41.6–45.4)
20.5 (19.0–22.0)
38.9 (37.0–40.7)

18.2 (16.8–197 West Virginia

3,553
53.3 (51.3–55.3)
16.7 (15.3–182)

45.4 (43.4-47.4) 14.4 (13.1-158 Sudden chest pain or discomfort, which is a symptom for heart attack but not for stroke. t Sudden confusion or trouble speaking; sudden numbness or weakness of face, arm, or leg, especially on one side; sudden trouble seeing in one ob eyes; sudden trouble walking, dizziness, or loss of balance; and a severe headache with no known cause. Confidence interval. 1 Aware of all five warning symptoms and knew that chest pain was not a warning symptom of stroke.

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ition, some states with heart disease and stroke

preveni programs are conducting activities to increase public

reness of the symptoms of heart attack and stroke and - importance of calling 9-1-1 (8).

he 2005 results in this report indicate no improvement iwareness of stroke warning symptoms from the 2001 1.sey (9), although direct comparisons cannot be made ause the areas participating in the optional heart attack

stroke module differed in 2005 (13 states and DC) from 11 (17 states and the U.S. Virgin Islands). In both sur, few respondents (17.2% in 2001 and 16.4% in 2005) gnized all five stroke warning symptoms, knew that sudchest pain is not a stroke symptom, and said they would 9-1-1 immediately if they thought someone was having coke or heart attack. Urgent public health efforts are needed -ncrease the percentage of respondents who meet these

isures and should focus on those symptoms with the least reness (i.e., severe headache with no known cause and den trouble seeing in one or both eyes). Disparities in awareness of stroke warning symptoms and wing the importance of telephoning 9-1-1 suggest that lic health efforts should be targeted to blacks, Hispan

men, and persons with less education. A 2006 study ermined that Hispanics who only spoke Spanish were

likely than Hispanics who also spoke English to be re of stroke warning symptoms and what action to take ney thought someone was having a stroke or heart attack :). In areas in which awareness of stroke warning sympis is lower, state and local health departments should sider working together to implement general public ireness campaigns. 'he findings in this report are subject to at least four itations. First, BRFSS excludes households without lline telephones, including those households with only ular telephones. Second, only 13 states and DC particied in the heart attack and stroke module in 2005; there·, the results might not be generalizable to the entire ulation of the United States. Third, the finding in this ort regarding the percentage of respondents who iden-:d all five stroke warning symptoms (43.6%) differed stantially from the previously reported estimate of 78% n the 2001 National Health Interview Survey (NHIS), ch was used as the initial baseline for objective 12-8 in Ithy People 2010 (7). However, the two results are not ctly comparable. NHIS results are representative of the

U.S. population, whereas the 2005 BRFSS respondents represented a population with landline telephones in 13 states and DC. Questioning in the two surveys also was structured differently. The NHIS questions did not cover the need to call 9-1-1 and also did not include an incorrect symptom as a check against persons who might answer “yes” to all the stroke symptom awareness questions without actually considering them. Finally, the data collected did not enable determination of whether participants who misidentified the incorrect stroke symptom did not know the correct answer or did not consider the question.

Receiving treatment quickly after a stroke is critical to lowering the risk for disability and even death. Rapid treatment requires that persons 1) recognize the warning symptoms of stroke and 2) call 9-1-1 immediately. These findings indicate a need to increase awareness of stroke warning symptoms in the entire population, and particularly among blacks, Hispanics, men, and persons at lower education levels. In addition, increased education efforts in multiple languages might help improve awareness among nonEnglish-speaking Hispanics and others. References 1. Thom TJ, Epstein FH. Heart disease, cancer, and stroke mortality

trends and their interrelations: an international perspective. Circula

tion 1994;90:574-82. 2. Lanska DJ, Peterson PM. Geographic variation in the decline of stroke

mortality in the United States. Stroke 1995;26:1159–65. 3. Heron MP. Deaths: leading causes for 2004. Natl Vital Stat Rep

2007;56(5). 4. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke

statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.

Circulation 2008;117:125–146. 5. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with

early stroke treatment: pooled analysis of ATLANTIS, ECASS, and

NINDS rt-PA stroke trials. Lancet 2004;363:768–74. 6. Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and

outcome after subarachnoid hemorrhage. JAMA 2004;291:866–9. 7. US Department of Health and Human Services. Healthy people 2010

midcourse review. Washington, DC: US Department of Health and Human Services; 2006. Available at http://www.healthypeople.gov/

data/midcourse. 8. CDC. State Heart Disease and Stroke Prevention Program. Atlanta,

GA: US Department of Health and Human Services, CDC; 2007.

Available at http://www.cdc.gov/dhdsp/state_program/index.htm. 9. CDC. Awareness of stroke warning signs—17 states and the U.S.

Virgin Islands, 2001. MMWR 2004;53:359–62. 10. DuBard Ca, Garrett J, Gizlice A. Effect of language on heart attack

and stroke awareness among U.S. Hispanics. Am J Prev Med 2006;30:189-96.

Arthritis as a Potential Barrier to Physical Activity Among Adults with Diabetes United States,

2005 and 2007 The American Diabetes Association and the American College of Sports Medicine agree that increasing physical activity among persons with diabetes is an important public health goal to 1) reduce blood glucose and risk factors for complications (e.g., obesity and hypertension) in persons with diabetes and 2) improve cardiovascular disease outcomes (1,2). Among adults with diabetes, co-occurring arthritis might present an underrecognized barrier to increasing physical activity, but to date this has not been directly studied. To estimate the prevalence of 1) diagnosed arthritis among adults with diabetes and 2) physical inactivity among adults with diabetes by arthritis status, CDC analyzed combined 2005 and 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS). This report describes the results of that analysis, which indicated that 1) arthritis prevalence was 52.0% among adults with diagnosed diabetes and 2) the prevalence of physical inactivity was higher among adults with diabetes and arthritis (29.8%) compared with adults with diabetes alone (21.0%), an association that was independent of age, sex, or body mass index (BMI). The higher prevalence of physical inactivity among adults who have both diabetes and arthritis suggests that arthritis might be an additional barrier to increasing physical activity. Health-care providers and public health agencies should consider addressing this barrier with arthritis-specific or general evidence-based self-management and exercise programs.

The BRFSS survey is a state-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized U.S. adult population aged 18 years and is conducted in all 50 states, the District of Columbia (DC), Guam, Puerto Rico, and the U.S. Virgin Islands. Diabetes was defined as a “yes” response to the question, “Have you ever been told by a doctor that you have diabetes?” Doctor-diagnosed arthritis was defined as a “yes” response to the question, “Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” This question is included in the BRFSS core questionnaire in oddnumbered years only. Physical activity level of respondents was determined from six questions* that asked about fre

quency and duration of participation in nonoccupati activities (i.e., lifestyle activities) of moderate and vigor intensity; those reporting no participation in such an ties were classified as inactive (i.e., engaged in no nono. pational physical activity), and all others as active. B was calculated from self-reported height and weight.

To obtain adequate sample sizes for greater statista. power, CDC combined data for the 50 states and DC fru 2005 and 2007, calculated estimates, and applied annual average weighting; 95% confidence intervals C were calculated using sample design factors to account: the multistage probability sample. To assess factors pole"tially confounding an association between doctor-diagnjx. arthritis and physical inactivity among those with dick. tes, data were combined across states/areas in unadjusi. and adjusted (by age, sex, and BMI) logistic regression models. Age groups were 18-44 years, 45-64 years. 2. >65 years. BMI groups were underweight/normal wees (BMI <25.0), overweight (BMI 25.0 to <30.0), and obes (BMI 230). Statistical significance was determined : nonoverlapping Cls. State-level estimates then were calci lated for the 50 states and DC (reported medians were bix. on these areas) and for Guam, Puerto Rico, and the l' Virgin Islands. Council of American Survey Organizati". (CASRO) response rates among the 50 states, DC, and three territories for 2005 ranged from 34.6% (New Jers to 67.4% (Alaska) (median: 51.1%), and cooperation rate ranged from 58.7% (California) to 85.3% (Minneso:2 (median: 75.1%). CASRO response rates for 2007 rangan from 26.9% (New Jersey) to 65.4% (Nebraska) (medan. 50.6%), and cooperation rates ranged from 49.6% (Net Jersey) to 84.6% (Minnesota) (median: 72.1%). S

During 2005 and 2007, the prevalence of arthritis amoca adults with diabetes was 52.0% (CI = 51.3%-52. compared with 26.9% (CI = 26.7%–27.1%) for all adue aged 218 years. The prevalence of arthritis among perses with diabetes was higher than in the general populativ for both sexes: males (45.9% (CI = 44.8%–47.1%) ver22.6 [CI = 22.3%-22.9%]); females (58.0% (CI = 5.1059.0%) versus 30.9% (CI = 30.7%–31.2%]), respectivei In addition, arthritis prevalence among persons with diate tes was higher than in the general population for all age grous (i.e., 18-44

years,
45-64
years,

and 265 years): 27.64 (CI = 25.7%-29.7%) versus 11.0% (CI = 10.8%-11.24 51.8% (CI = 50.8%-52.9%) versus 36.4% (CI = 36.14

* Available at http://www.cdc.gov/brfss/questionnaires/pdf-ques/2005brfss.pdf and http://www.cdc.gov/brfss/questionnaires/pdf-ques/2007brfss.pdf.

* 2005 BRFSS data quality report available at http://www.cdc.gov.

technical_infodata/pdf/2005summarydataqualityreport.pdf. $ 2007 BRFSS data quality report available at http://www.cdc.gou bem technical_infodata/pdf/2007summarydataqualityreport.pdf.

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8%), and 62.4% (CI = 61.3%-63.5%) versus 56.2%

55.8%–56.6%), respectively. Prevalence of physical -ctivity was lowest among adults without arthritis or diatas (10.9% (CI = 10.7%-11.1%]), higher among adults h arthritis alone (17.3% (CI = 17.0%-17.6%]) and betes alone (21.0% (CI = 20.0%–22.1%]), and highamong adults with both conditions (29.8% (CI = 0%–30.7%]) (Figure). In logistic regression analyses, the djusted odds ratio (OR) for the association between docdiagnosed arthritis and physical inactivity among adults ch doctor-diagnosed diabetes was 1.6 (CI = 1.3–1.7);

isted for age and sex, the OR was 1.4 (CI = 1.3–1.5); and - isted for age, sex, and BMI, the OR was 1.3 (CI = 1.2–1.4). State-specific analyses, the state median prevalence estimate ohysical inactivity among adults with diabetes and arthriwas 28.9% (range: 20.2% in California to 46.4% in Tensee). The state median prevalence estimate of physical -ctivity among adults who had diabetes and no arthritis

19.5% (range: 9.0% in Alaska to 30.2% in West Virginia) ble). ported by: J Bolen, PhD, J Hootman, PhD, CG Helmick, MD, lurphy, PhD, G Langmaid, Div of Adult and Community Health, Caspersen, PhD, Div of Diabetes Translation, National Center for onic Disease Prevention and Health Promotion, CDC. itorial Note: In the United States, approximately 20.6 lion adults were reported to have diabetes in 2005 (3), h nearly seven in 10 having diabetes diagnosed by a .lth professional. In addition, during 2003–2005, proximately 46.4 million adults had arthritis (4). cause physical activity is a recommended selfnagement strategy for both conditions, examining the oct of co-existing arthritis and diabetes on physical vity levels is warranted. The results of this analysis indicated that, during 2005 I 2007, doctor-diagnosed arthritis affected approximately f of adults with doctor-diagnosed diabetes. The prevace of self-reported physical inactivity was significantly her among those with arthritis and diabetes than among se with diabetes alone. This association remained sigcant after adjustment for age, sex, and BMI, factors that zht have otherwise explained the association. Statecific estimates were consistent with the overall findings, h state-to-state differences likely attributable to differes in the distribution of factors associated with both uritis and physical inactivity in the state population. ause BRFSS data are cross-sectional, they can only demtrate an association; the temporal sequence of condition et is unknown. he associations between arthritis and physical inactivamong adults with diabetes found in this analysis sug

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gest that arthritis might be a barrier to being physically active in this population. Being more physically active (e.g., through aerobic exercise or strength training) can benefit persons with either arthritis or diabetes and those with both conditions (1). Persons with diabetes who are inactive and become more active benefit from improved physical function and glucose tolerance (5), but they face the same common barriers to being more physically active as most adults, such as lack of time, competing responsibilities, lack of motivation, and difficulty finding an enjoyable activity (6). Those who also have arthritis face additional diseasespecific barriers, such as concerns about aggravating arthritis pain (6) and causing further joint damage, and they might be unsure about which types and amounts of activity are safe for their joints. Health-care providers interested in improving diabetes management might want to especially consider arthritis-related barriers among persons with diabetes who are physically inactive.

Specially tailored self-management education interventions, such as the Chronic Disease Self Management Program (7) and the arthritis-specific Arthritis Foundation Self-Help Program, help adults learn to manage arthritis pain and discuss how to safely increase physical activity (8). In addition, several exercise programs, including EnhanceFitness (2), the Arthritis Foundation Exercise Program, and the Arthritis Foundation Aquatics Program (8),

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