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. Author manuscript; available in PMC: 2023 Feb 20.
Published in final edited form as: Am J Prev Med. 2022 May 23;63(4):513–520. doi: 10.1016/j.amepre.2022.04.003

Obesity and Eligibility for Obesity Treatments Among Adults With Disabilities in the U.S.

Matthew J Townsend 1, Mechelle D Claridy 2, Simar S Bajaj 3, Lucy Tu 4, Fatima C Stanford 5,6
PMCID: PMC9940942  NIHMSID: NIHMS1867649  PMID: 35613976

Abstract

Introduction:

Obesity has been associated with disability; yet, the proportion who meet clinical criteria for obesity treatment among adults with disabilities remains poorly defined. Characterization of obesity and treatment eligibility by disability type may prioritize high-need groups. This study assessed the prevalence of obesity and eligibility for antiobesity pharmacotherapy and/or bariatric surgery in adults with disability.

Methods:

This cross-sectional weighted analysis of the 2019 National Health Interview Survey, including self-reported health and sociodemographic information, was conducted in 2021. Burden of obesity defined by BMI and odds of meeting consensus criteria for antiobesity pharmacotherapy and/or surgery were calculated by functional disability type: vision, hearing, cognition, communication, mobility, and self-care.

Results:

From 29,170 community-dwelling adult respondents (59.1% response), the overall prevalence of disability was 10%. The prevalence of obesity among adults with a disability was 40.1% vs 30.5% for U.S. adults overall (p<0.0001). An estimated 17.1% with disability met the criteria for both bariatric surgery and antiobesity pharmacotherapy; another 39.8% were eligible for pharmacotherapy alone (vs 7.9% and 33.2%, respectively, for adults overall; p<0.0001). In fully adjusted models, disability was associated with greater ORs for mild obesity (OR=1.2; 95% CI=1.1, 1.4), moderate–severe obesity (OR=2.1; 95% CI=1.8, 2.3), and criteria for bariatric surgery (OR=2.4; 95% CI=2.1, 2.7) and pharmacotherapy (OR=1.3; 95% CI=1.2, 1.4). Mobility, self-care, and cognition disabilities were associated with eligibility for bariatric surgery and antiobesity pharmacotherapy.

Conclusions:

Individuals with disabilities have higher odds of obesity and eligibility for antiobesity treatments. Comorbidities should be considered, accommodations should be provided, and insurance coverage should be expanded to ensure access to antiobesity treatments for adults with disabilities.

INTRODUCTION

Individuals with 1 or more disabilities encompass a large portion of the U.S. population—an estimated 12.6% or more than 40 million Americans—yet, they are frequently overlooked in obesity prevention and treatment efforts.1,2 Few studies have estimated the prevalence of obesity among individuals with disabilities in the U.S. as the rates of obesity have risen disproportionately to disability rates and as pharmacologic and surgical treatment options for obesity have expanded.3 In an analysis of the 1994–1995 National Health Interview Survey (NHIS), Weil and colleagues4 found a near two-fold OR of obesity among adults with disabilities after adjustment for sociodemographic factors. The overrepresentation of obesity (as defined by a BMI ≥30 kg/m2) and severe obesity (BMI ≥40 kg/m2) among adults with disabilities has been supported by several subsequent analyses of the National Health and Nutrition Examination Survey (NHANES).5–7 The most recent available analysis included only older individuals (aged ≥60 years), reporting that the relative odds of functional impairment among those with obesity versus those without obesity increased from 1988–1994 to 1999–2004 and plateaued from 1999–2004 to 2005–2012.7

Major increases in the prevalence of obesity and disability necessitate an updated analysis. The age-adjusted prevalence of obesity among U.S. adults increased from 30.5% in 1999–2000 to 42.4% in 2017–2018.8 These changes have been accompanied by modest, nonparallel increases in disability prevalence from 11.9% in 2010 to 12.8% in 2016.2 Despite the expansion of antiobesity medications approved by the U.S. Food and Drug Administration (FDA) and improved bariatric procedural techniques, pharmacologic and surgical treatments for obesity remain dramatically underutilized.9,10 Joint guidelines from the American College of Cardiology, American Heart Association, and The Obesity Society recommend the option of antiobesity medications with a BMI ≥30 or BMI ≥27 with comorbidity and referral for evaluation for bariatric surgery with a BMI ≥40 or BMI ≥35 with comorbidity.11 Yet, the American Society for Metabolic and Bariatric Surgery estimated that only 1.1% of qualified patients received bariatric surgery in 201812; the use of antiobesity prescription medications among adults with obesity, at approximately 2.9%, is similarly low.13

An updated characterization of adults with obesity, related health conditions, and disability may elucidate how this at-risk intersectional population might benefit from obesity prevention efforts and evidence-based pharmacologic and bariatric treatments for obesity. This study analyzes the 2019 NHIS to compare the prevalence of obesity and eligibility for obesity pharmacotherapy and bariatric surgery by disability status.

METHODS

Study Sample

This retrospective, cross-sectional, observational study utilized adult responses from the most recent complete NHIS (NHIS 2019).14 Conducted by the U.S. National Center for Health Statistics since 1960, the NHIS is a household survey that polls approximately 30,000 community-dwelling U.S. adults annually on demographic, socioeconomic, and health status questions, including functional limitations. NHIS height and weight data are self-reported and are therefore inclusive to individuals with disabilities who are unable to stand independently on a scale; these individuals are excluded from measurements in other national household surveys, including the NHANES. NHIS questionnaire content and sampling structure were dramatically revised in 2019, preventing pooled or longitudinal analysis with older data. NHIS 2020 data were not incorporated given the disruption to in-person interviews and data reliability because of coronavirus disease 2019 (COVID-19). Because NHIS data are deidentified and are publicly available, this secondary analysis was not characterized as human subjects research and did not require IRB review.

Measures

NHIS disability-related questions and the definitions of disability in this study were structured according to the Washington Group on Disability Statistics Short Set on Functioning, which is based on the International Classification of Functioning, Disability, and Health from the WHO, recognizing disability as a complex, heterogeneous category. The Washington Group defines disability as functional difficulty (a lot of difficulty or cannot do at all compared with no difficulty or some difficulty) in 1 of 6 domains: vision, hearing, communication, cognition (difficulty remembering or concentrating), mobility (walking or climbing steps), and self-care (such as washing all over or dressing).14,15 It does not define disability on the basis of specific medical diseases. Limitations were queried for accommodated vision and hearing (glasses or hearing aid as relevant) and unaccommodated function in all other domains. BMI was calculated from self-reported height and weight. The primary outcome was weight class defined by BMI: underweight (BMI<18.5), normal weight (18.5–24.9), overweight (25–29.9), Class I (mild) obesity (30–34.9), and Classes II–III (moderate–severe) obesity (BMI≥35). Secondary outcomes included eligibility for antiobesity pharmacotherapy (BMI≥30 or ≥27 plus at least 1 comorbidity) and bariatric surgery (BMI≥40 or ≥35 plus comorbidity) on the basis of consensus guidance from the FDA and NIH.16,17 Conditions considered obesity-related comorbidities were diabetes, hyperlipidemia, hypertension, coronary heart disease, angina, heart attack, stroke, and arthritis on the basis of established associations and availability in the NHIS.14,18,19

Statistical Analysis

Strata and clusters were included to account for the complex survey design. Sampling weights that adjust for nonresponse and unequal selection probabilities are provided in the NHIS to support the generation of nationally representative estimates. Sampling weights were applied in all analyses. Analyses were performed in May–July 2021 using SAS 9.4 (Cary, NC).20

Estimation procedures were used to calculate means, weighted frequencies, percentages, and SEs of the total population and respondents with disabilities by sociodemographic variables (age, race/ethnicity, region, marital status, education, insurance status, and income level) and other select characteristics (food security, problems paying bills in the last 12 months, delayed medical care because of cost, blood pressure check, pain, depressive symptoms, anxiety symptoms, and smoking status). These characteristics were selected from available NHIS variables on the basis of a priori suspicion that these may feasibly mediate the relationship between disability and weight status. Taylor series linearization methods were used for variance estimation.

Design-adjusted chi-square tests were used to compare disability prevalence between weight classes and treatment eligibility categories. Rao-Scott chi-square tests were used to compare education and income levels between disability categories. Multinomial logistic regressions were used to estimate the adjusted associations between disability status and weight status, with underweight/normal weight (BMI<25) as the reference group. Multinomial logistic regressions were also used to estimate the adjusted associations between eligibility for pharmacologic or surgical treatment of obesity and disability status. The treatment eligibility outcome contained 3 levels: (1) adults with underweight, normal weight, or otherwise not meeting the criteria for obesity treatment (reference group); (2) adults eligible for antiobesity pharmacotherapy alone; and (3) adults eligible for both antiobesity pharmacotherapy and bariatric surgery. The reference group for each disability category consisted of adults without a specific disability. Influential factors were identified using least absolute shrinkage and selection operator. Each model adjusted for age, sex, race/ethnicity, marital status, education, insurance status, smoking status, and ability to pay bills in the past 12 months.14

RESULTS

Of 29,170 U.S. adults who completed the NHIS in 2019 (59.1% response), 2,906 (10.0%) reported at least 1 disabling condition. Disability was reported across the domains of mobility (6.4% of respondents), self-care (3.1% of respondents), cognition (2.2% of respondents), hearing (1.8% of respondents), vision (1.6% of respondents), and communication (0.7% of respondents). The weighted population estimate of U.S. adults with a disability was 56.2% female and 68.6% White, with a mean age of 61 years; the largest percentage resided in the U.S. South (42.4%). Living alone (51.7%), having a high school education or less (34.6%), being insured by Medicare (41.7%), and having an annual household income of <$35,000 (39.3%) were also more frequent among those with disabling conditions (Appendix Table 1, available online). Experiencing pain most days or every day was frequent among adults with disabling conditions, reported most by those with mobility (71.9%), self-care (70.0%), and cognitive (53.8%) disabilities (Appendix Table 2, available online).

The prevalence of obesity among adults with a disability was 40.1% vs 30.5% for adults overall (p<0.0001) (Table 1). Among adults with disability, 33.0% had overweight, 22.3% had mild (Class I) obesity, and 17.8% had moderate–severe (Classes II–III) obesity, compared with rates of 35.5%, 19.7%, and 10.8%, respectively, in the overall weighted sample (p<0.0001). There were significant associations between weight status and most disabling conditions. Cognition, communication, mobility, and self-care disabilities were each significantly associated with higher weight status. Moderate–severe obesity in particular was more prevalent among those with cognition, self-care, and mobility disabilities.

Table 1.

Weight Status by Disability Among U.S. Adults.

Disabilitya Weight categoryb Weighted % (SE)
Underweight (n=285) Normal weight (n=9,574) Overweight (n=10,399) Mild obesity (n=5,771) Moderate–severe obesity (n=3,141) p-value
Overall 0.9 (0.1) 33.1 (0.4) 35.5 (0.4) 19.7 (0.3) 10.8 (0.2)
Any disability 1.4 (0.2) 25.5 (0.9) 33.0 (1.1) 22.3 (0.9) 17.8 (0.9) <0.0001
Vision 1.7 (0.6) 27.0 (2.5) 39.3 (2.9) 20.4 (2.2) 11.6 (1.9) 0.1000
Hearing 1.7 (0.7) 28.5 (2.3) 37.8 (2.5) 19.8 (2.0) 12.2 (1.8) 0.1908
Cognition 0.5 (0.3) 34.8 (2.4) 30.3 (2.2) 19.0 (2.0) 15.5 (1.7) 0.0051
Communication 2.2 (1.9) 43.9 (1.0) 30.4 (0.7) 13.3 (0.5) 10.1 (0.7) 0.0112
Mobility 1.2 (0.3) 20.8 (1.1) 30.1 (1.4) 25.4 (1.2) 22.5 (1.2) <0.0001
Self-care 1.8 (0.5) 28.7 (1.9) 31.8 (2.0) 22.2 (1.7) 15.5 (1.7) <0.0001
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Note: Boldface indicates statistical significance (p<0.05).

a

Disability responses include those having a lot of difficulty or cannot do at all. Percentages were weighted to reflect the U.S. adult population of 227.2 million.

b

BMIs in each weight category: BMI<18.5 kg/m2 for underweight, 18.5–24.9 kg/m2 for normal weight, 25.0–29.9 kg/m2 for overweight, 30.0–34.9 kg/m2 for mild (Class I) obesity, and ≥35.0 kg/m2 for moderate–severe (Classes II–III) obesity.

There were significant associations between obesity treatment eligibility and disabling conditions (Table 2). Among adults with disabling condition(s), 17.1% were eligible for both pharmacotherapy and bariatric surgery, and an additional 39.8% were eligible for pharmacotherapy. Pharmacotherapy eligibility alone was more prevalent among adults with vision, mobility, and self-care disabilities, whereas both pharmacotherapy and bariatric surgery eligibility were more prevalent among those with mobility disabilities than among adults overall.

Table 2.

Eligibility for Obesity Treatment by Disability Status Among U.S. Adults

Disabilitya Treatment categoryb Weighted % (SE)
Underweight/Normal weight (n=9,859) Overweight/Obesity but treatment ineligible (n=6,993) Pharmacotherapy eligible (n=9,887) Pharmacotherapy and bariatric surgery eligible (n=2,431) p-value
Overall 34.0 (0.4) 24.9 (0.3) 33.2 (0.4) 7.9 (0.2)
Any disability 26.7 (1.0) 16.4 (0.9) 39.8 (1.1) 17.1 (0.9) <0.0001
Vision 28.7 (2.6) 18.7 (2.3) 41.0 (2.5) 11.6 (1.9) 0.0003
Hearing 30.2 (2.4) 20.3 (2.3) 37.6 (2.4) 11.9 (1.8) 0.0030
Cognition 35.3 (2.4) 17.8 (1.8) 33.8 (2.4) 13.1 (1.5) <0.0001
Communication 46.1 (4.1) 20.2 (3.8) 23.8 (3.6) 9.9 (2.2) 0.0076
Mobility 22.0 (1.1) 13.7 (1.0) 42.2 (1.4) 22.2 (1.2) <0.0001
Self-care 30.6 (1.9) 14.0 (1.5) 40.2 (2.1) 15.2 (1.6) <0.0001
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Note: Boldface indicates statistical significance (p<0.05).

a

Disability responses include those having a lot of difficulty or cannot do at all. Percentages were weighted to reflect the U.S. adult population of 227.2 million.

b

Treatment status categories include underweight/normal weight (BMI<25 kg/m2), overweight/obesity but treatment ineligible (BMI=25.0–26.9 kg/m2 with or without comorbidity or BMI 27.0–29.9 kg/m2 without comorbidity), pharmacotherapy eligible (BMI=27.0–29.9 kg/m2 with comorbidity, BMI=30.0–34.9 kg/m2 with or without comorbidity, or BMI=35.0–39.9 kg/m2 without comorbidity), and pharmacotherapy and bariatric surgery eligible (BMI=35.0–39.9 kg/m2 with comorbidity and BMI≥40.0 kg/m2 with or without comorbidity).

After adjusting for age, sex, race/ethnicity, marital status, education, insurance status, smoking status, and ability to pay bills, adults with at least 1 disabling condition were 20% more likely to have mild obesity (AOR=1.2; 95% CI=1.1, 1.4) and more than twice as likely to have moderate–severe obesity (AOR=2.1; 95% CI=1.8, 2.3) (Table 3). Among disability categories, the largest odds increase for moderate–severe obesity was observed with mobility (AOR=3.0; 95% CI=2.6, 3.5). Individuals with cognitive and communicative disabilities were 20% and 60% less likely, respectively, to have mild obesity than those without disability; these associations were not significant for moderate–severe obesity. No meaningful relationships were observed between vision or hearing and the odds of overweight or obesity.

Table 3.

AORs of Weight Status by Type of Disability.

Disability AOR (95% CI)a
Overweight Mild (Class I) obesity Moderate–severe (Classes II–III) obesity
Any disability 1.0 (0.9, 1.2) 1.2 (1.1, 1.4) 2.1 (1.8, 2.3)
Vision 1.1 (0.9, 1.4) 1.0 (0.7, 1.3) 1.0 (0.7, 1.4)
Hearing 0.9 (0.8, 1.2) 1.0 (0.7, 1.3) 1.0 (0.7, 1.3)
Cognition 0.8 (0.6, 0.9) 0.8 (0.5, 0.9) 1.2 (0.9, 1.5)
Communication 0.5 (0.3, 0.7) 0.4 (0.3, 0.7) 0.7 (0.4, 1.1)
Mobility 1.1 (1.0, 1.3) 1.7 (1.4, 1.9) 3.0 (2.6, 3.5)
Self-care 0.9 (0.7, 1.0) 1.0 (0.8, 1.2) 1.3 (1.1, 1.6)
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Note: Boldface indicates statistical significance (95% CI of the AOR does not contain 1.0).

a

The reference group for each disability category is adults without the specific disability (some difficulty/none at all). The reference group for each weight status category is adults without overweight or obesity (underweight and normal weight). Each model adjusted for age, sex, race/ethnicity, marital status, education, insurance status, smoking status, and ability to pay bills in the past 12 months.

In similar fully adjusted models, adults with at least 1 disabling condition were 140% more likely to be eligible for both bariatric surgery and pharmacotherapy (AOR=2.4; 95% CI=2.1, 2.7) and 30% more likely to be eligible for obesity pharmacotherapy alone (AOR=1.3; 95% CI=1.2, 1.4) (Table 4). Mobility, self-care, and cognitive disabilities were associated with increased odds of eligibility for both surgical and medical treatment; only mobility was associated with increased odds of eligibility for pharmacotherapy alone. No meaningful relationships were observed between vision or hearing and the odds of obesity treatment eligibility.

Table 4.

AORs of Eligibility for Obesity Treatment by Type of Disability.

Disability AOR (95% CI)a
Pharmacotherapy eligible Pharmacotherapy and bariatric surgery eligible
Any disability 1.3 (1.2, 1.4) 2.4 (2.1, 2.7)
Vision 1.1 (0.9, 1.4) 1.1 (0.8, 1.6)
Hearing 1.0 (0.9, 1.3) 1.1 (0.8, 1.5)
Cognition 0.9 (0.7, 1.1) 1.4 (1.1, 1.8)
Communication 0.5 (0.4, 0.8) 0.9 (0.6, 1.5)
Mobility 1.5 (1.3, 1.7) 3.3 (2.9, 3.9)
Self-care 1.1 (1.0, 1.3) 1.5 (1.2, 1.9)
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Note: Boldface indicates statistical significance (95% CI of the AOR does not contain 1.0).

a

The reference group for each disability category is adults without the specific disability (some difficulty/none at all). The reference group for treatment category is adults ineligible for treatment, underweight, or with normal weight. Each model adjusted for age, sex, race/ethnicity, marital status, education, insurance status, smoking status, and ability to pay bills in the past 12 months.

DISCUSSION

This study elucidates the characteristics of adults with obesity and disability in the U.S. on the basis of the 2019 NHIS. Adults with at least 1 disability had higher odds of mild (Class I) and moderate–severe (Classes II–III) obesity and higher odds of eligibility for antiobesity pharmacotherapy and bariatric surgery than adults without a disability after adjustment for key demographic and socioeconomic characteristics. These effects were particularly pronounced for mobility and self-care impairments. No statistically significant differences in the odds of obesity or eligibility for obesity treatment arose for visual and hearing disabilities.

Weil and colleagues4 (2002) and others previously showed a higher prevalence of obesity among adults with disabling sensory, physical, and mental health conditions.5,7 This work contributes an updated and more specific examination of disability using categories of vision, hearing, cognition, communication, mobility, and self-care on the basis of consensus measures from the Washington Group on Disability Statistics.21 To the authors’ knowledge, no previous studies have described eligibility for obesity treatment by disability type. Given that antiobesity pharmacotherapy and bariatric surgery are effective but underutilized treatments, the finding that adults with disabling condition(s), particularly related to mobility, self-care, and cognition, are more likely to be eligible for these 2 categories of obesity treatment highlights the need for public health outreach programs that identify individuals in need from this intersectional population and connect them for treatment evaluation.9,10 Significantly increased odds of pharmacotherapy and bariatric surgery eligibility emerged for individuals with cognitive disabilities–an association not shown in parallel models for odds of obesity–highlighting the need to consider the burden of related health conditions alongside BMI in individual- and population-based risk stratification. Factors such as race and SES have been linked to disparities in access to bariatric surgery.22 Similar disparities may arise among adults with disabilities in accessing evidence-based obesity care.

Multiple explanations may underlie the observation that individuals with at least 1 disability are more likely to have mild or moderate–severe obesity than the general population. For instance, diagnostic overshadowing of adults with disabilities may contribute to the development of their obesity owing to substandard care and overlooked symptoms.23 Increased weight, if noticed, may be attributed to the disability and thus minimized. Obesity-related comorbidities may similarly be overshadowed and thus not captured in assessments for antiobesity treatment options. Another likely contributing factor is that adults with certain disabilities have trouble exercising regularly because of an array of personal and environmental barriers, including an absence of inclusive physical activity.24 Individuals with a disability may also face obstacles in accessing nutritionally adequate diets.25 These difficulties can beget a vicious cycle, in which inactivity exacerbates obesity, obesity worsens disability-related limitations, and disability-related limitations hinder exercise.4,26 Obesity and disability are frequently codeterminative.

Even where obesity and medical criteria for pharmacologic and/or surgical treatment of obesity are identified, additional barriers to treatment likely exist on the basis of cognitive, sensory, and/or other physical impairments. Overlapping systems of discrimination and nonaccommodation against people with obesity and disability may result in undertreatment. Higher perceived discrimination has been associated with reduced health-care seeking among individuals with disabilities and those with obesity.27,28 Inclusive, accessible communication (e.g., audiovisual and print materials, qualified interpreters) and adaptations, including longer clinical visits and increased adjunctive behavioral and nutritional counseling, have been proposed as potentially useful additional supports for individuals with disabilities who pursue antiobesity pharmacotherapy or bariatric surgery.29 Although severe intellectual disabilities that limit comprehension of risks, expected benefits of treatment, and alternatives may contraindicate bariatric surgery or pharmacotherapy among a minority of adults with disability, such barriers to informed consent cannot solely explain the differential gaps in treatment eligibility and utilization in this population.

Insurance coverage may impose additional barriers for individuals with disabilities seeking antiobesity treatments. Most adults with disabling condition(s) in this study held Medicaid (13.4%) or Medicare (41.7%); whereas Medicaid coverage for antiobesity pharmacotherapy varies widely from state to state, Medicare excludes antiobesity medications entirely from prescription drug plans for beneficiaries.30 The Treat and Reduce Obesity Act introduced to Congress (2021–2022) proposes to expand Medicare benefits for behavioral therapy for obesity and to permit the coverage of FDA-approved antiobesity medications under the Medicare prescription drug benefit.31 The present results suggest that many adults in the intersectional population with disability and obesity would gain access to treatment under such legislation. The coverage landscape for bariatric surgery is more favorable. Medicare covers gastric bypass, sleeve gastrectomy, laparoscopic banding, or biliopancreatic diversion with duodenal switch but requires not only BMI and comorbidity-based criteria but also documented evidence of obesity for at least 5 years, participation in a medical weight loss program, physician’s letter of support, and psychological evaluation.32 As of 2017, Montana and Mississippi are the only 2 states that do not cover at least 1 bariatric procedure under their Medicaid plans.33

This present analysis of 2019 NHIS respondents, in contrast to Weil and colleagues’ analysis of 1994–1995 respondents, did not show significantly increased odds of obesity among adults with vision- or hearing-related disabilities.4 Several potential explanations exist. Individuals with vision- and hearing-related disabilities are frequently wealthier and more educated than other disability subgroups.34 In this study’s weighted samples, the vision and hearing disability groups had income and education distributions significantly different from those of the mobility, self-care, and any disability groups (Appendix Table 5, available online). Disparities in these social determinants of health, insurance status, tobacco use, and/or ability to pay bills (included in the least absolute shrinkage and selection operator–derived models) may affect the observed relationships between disability and obesity. The epidemiology of obesity and disability may also have changed over the interim 25-year period since the previous analysis. Changes to U.S. social safety net policies include regulations introduced by the Affordable Care Act that permit people with disabling condition(s) to earn greater income while still qualifying for Medicaid, reducing health insurance–motivated disability enrollment.35 The major NHIS survey redesign from 2018 to 2019 limits the analysis of obesity trends over time in adults with disabilities, including direct comparisons with previous surveys that utilize different disability definitions and questions. Follow-up studies of the vulnerable population with vision- or hearing-related disabilities may clarify these relationships.

Limitations

Weight categories were defined using BMI, an imperfect measure with nonuniform health implications across racial/ethnic groups.36 BMI may also underestimate obesity in individuals with disability-related muscle atrophy.37 Self-reported weight data are subject to reporting biases and are typically underestimated, as reflected in an overall adult obesity prevalence estimate of 30.5% in the NHIS data vs 42.4% in most recent epidemiologic estimates.8 Therefore, the calculations of obesity prevalence and treatment eligibility must be considered highly conservative. Although the NHIS aims to achieve a nationally representative sample—and, unlike NHANES, includes those who cannot stand independently—it excludes institutionalized populations such as residents of long-term care facilities. The Washington Group short set is sensitive across 6 core functional domains but may underreport psychosocial difficulties that do not impact cognition, communication, or self-care.38 Deviation from the recommended severity cut off (a lot of difficulty or cannot do at all) to define disability would lead to a change in disability prevalence estimates. Finally, although the associations found in this study help to define and support this intersectional population, a cross-sectional design does not permit conclusions on causality between obesity and disability. Nevertheless, this analysis provides a national characterization of the elevated rates of obesity and eligibility for antiobesity treatments among U.S. adults with disabling condition (S) compared with those among the general adult population.

CONCLUSIONS

Individuals with disability face disproportionate levels of obesity, suggesting a need for focused preventive medicine interventions of screening, nutritional and behavioral supports, and connection to medical evaluation for pharmacotherapy and bariatric surgery, where appropriate. Wide gaps exist between the population eligible and the group utilizing these evidence-based therapies. As implicated by significantly higher rates of antiobesity treatment eligibility but not BMI-defined obesity rates among certain subgroups, including individuals with cognitive disabilities, screening measures must incorporate coexisting health conditions alongside BMI in identifying patients who can benefit from medical treatment for obesity. Discussions of treatment options must accommodate any cognitive, communicative, or audiovisual differences. Expanded insurance-benefit coverage of pharmacotherapy would assist the substantial proportion of adults with disability on Medicaid, Medicare, or private insurance with currently sparse coverage. Efforts to support adults with obesity and disability, identify their needs through public health outreach, and ensure their access to obesity treatment should be endorsed.

Supplementary Material

Appendix

ACKNOWLEDGMENTS

The authors thank Dr. Ellen Meara (Harvard T.H. Chan School of Public Health, Boston, MA) for her valuable insights on disability related to this work.

The National Center for Health Statistics is responsible for the raw National Health Interview Survey data but not for the authors’ analyses, interpretations, or conclusions.

FCS is funded by the NIH-National Institute of Diabetes and Digestive and Kidney Diseases grants P30 DK040561 and L30 DK1187100, each outside of the submitted work.

No financial disclosures were reported by the authors of this paper.

Footnotes

SUPPLEMENTAL MATERIAL

Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j.amepre.2022.04.003.

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NIHMS1867649-supplement-Appendix.docx (35.4KB, docx)

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