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Life with Arthritis in Canada : A personal and public health challenge

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Chapter One: What is arthritis and how common is it?

I was quite concerned and depressed about the diagnosis as I had an aunt who at that time was already quite "deformed" by her rheumatoid arthritis. I was only about 27 at the time, with two young children and very active physically. I did not want to face this change in my lifestyle.

— Person living with rheumatoid arthritis

I was only six and a half years old, just remember being scared to be in the hospital. I was in there for a month while they took daily blood and skin tests. My disease went into remission at age 11, so I enjoyed a normal life, enjoyed some school sports and got two jobs after school, took karate, played paintball. But at age 24, the disease came roaring back, affecting multiple joints—some of which were not touched before—causing complete and permanent disability. I have not worked since. Became a shut in. Medicine in those days was not very effective.

— Person living with rheumatoid arthritis

Introduction

This chapter addresses two key questions: "What is arthritis?" and "How common is it?" The first section describes arthritis in general and its different types. The second section presents the prevalence of arthritis in the Canadian population according to personal characteristics, place of residence and projects the prevalence of arthritis into the future.

What is arthritis?

Put simply, arthritis means "joint inflammation" and encompasses more than 100 rheumatic diseases and conditions that affect the joints, the tissues that surround the joint and other connective tissue. The most familiar types of arthritis are osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, childhood or juvenile idiopathic arthritis (JIA), and gout (Table 1-1). For further information about the different types of arthritis see the Glossary.

Table 1-1 Major types of arthritis
  Osteoarthritis
(OA)
Rheumatoid Arthritis (RA) Ankylosing Spondylitis (AS) and other spondyloarthropathies Connective tissue disorders Table 1 - Footnote * Juvenile Idiopathic Arthritis (JIA) Gout
Table 1 - Footnote *
Also known as Systemic Autoimmune Rheumatic Diseases (SARDS) in Canada.
Background OA results from deterioration of cartilage and thickening of the bones underneath, in one or more joints. This leads to joint damage, pain and stiffness. Typically affects hands, feet, knees, spine and hips. RA is caused by the body's immune system attacking the body's joints (primarily hands, wrists and feet). This leads to pain, inflammation and joint damage. RA may also involve other organ systems such as eyes, heart and lungs. Inflammatory arthritis of the spine. Causes pain and stiffness in the back and possibly a bent posture. Usually characterized by acute painful episodes and remissions. Disease severity varies widely among individuals.

Other spondyloarthropathies include psoriatic arthritis and Reiter's disease.
Connective tissue disorder causing skin rashes, joint and muscle swelling, and pain. May also affect organs. Fluctuates over time, with flare-ups and periods of remission.

Connective tissue disorders include systemic lupus erythematosus, scleroderma, polymyositis, dermatomyosi- tis, and Sjögren's syndrome.
JIA is a rare chronic condition of children and adolescents. Although rarely fatal, the condition is long-term and associated with serious physical disability. Gout is caused by too much uric acid in the body. Most often affects the big toe but can also affect the ankle, knee, foot, hand, wrist or elbow.

Gout can be episodic, with long periods of remission followed by flare-ups for days to weeks, or it can become chronic.
Prevalence Affects more than 10% Canadian adults. Affects approximately 1% of Canadian adults (at least twice as many women as men). Affects approximately 1% of Canadian adults (three times more men than women). Affects approximately 0.05% of Canadian adults (up to ten times more women than men). Affects approximately 5 to 10 per 10,000 children under the age of 16 years. Affects up to 3% of Canadian adults (four times more men than women).
Possible risk factors Age, heredity, obesity, previous joint injury. Hormones, heredity, ethnicity. Heredity and possibly, gastrointestinal or genitourinary infections and psoriasis (in the case of psoriatic arthritis). Heredity, hormones and possibly a variety of environmental factors. Onset may coincidentally follow a routine infection or injury, but such common events do not cause JIA. The immune system may be responsible for the inflammation. Heredity, certain medications (e.g. diuretics), alcohol and certain foods (high intake of purine rich foods such as red meat and seafood).
Possible management strategies Treatments can decrease pain and improve joint mobility, and include:
  • Medication (e.g. analgesics, anti-inflammatory drugs)
  • Exercise
  • Physiotherapy/ Occupational therapy
  • Weight loss/Healthy weight
  • Participation in self- management education programs
In severe cases, the entire joint — particularly the hip or knee — may be replaced through surgery.
Early, aggressive treatment by a rheumatologist can prevent joint damage.
  • Medication (e.g. non- steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) and biologic response modifiers)
  • Exercise
  • Physiotherapy / 0ccupa- tional therapy
  • Healthy weight
  • Participation in self- management education programs
Medications similar to those used for other types of arthritis are often prescribed to treat AS.
  • Exercise
  • Physiotherapy / 0ccupa- tional therapy
  • Healthy weight
  • Participation in self- management education programs
If damage is severe, surgery may be considered
Treatment goal is to control symptoms, reduce the number of flare-ups and prevent damage.
  • Medication (e.g. analgesics, anti-inflammatory drugs, cortisone and disease-modifying anti-rheumatic drugs (DMARDs))
  • Exercise
  • Physiotherapy/ Occupational therapy
  • Healthy weight
  • Participation in self- management education programs
  • Balanced diet and avoiding excessive alcohol consumption
  • Medication (e.g. non-steroidal anti-inflammatory drugs (NSAIDs) are often used to treat JIA to help reduce pain and swelling and decrease stiffness)
  • Exercise
  • Physiotherapy/ Occupational therapy: to minimize long-term damage to joints and muscles and to preserve function
  • Healthy weight
  • Participation in self- management education programs
  • Medication (e.g. non- steroidal anti-inflammatory drugs (NSAIDs) and allopurinol can be used on a long-term basis to reduce uric acid levels and prevent future attacks.
  • Exercise
  • Physiotherapy/Occupa- tional therapy
  • Healthy weight
  • Participation in self- management education programs

Text Equivalent - Table 1-1



Most types of arthritis are characterized by pain, aching, stiffness and swelling in and around joints or elsewhere in the musculoskeletal system.Footnote 1 They can affect the structure and functioning of the joints, leading to increased pain, disability and difficulty in performing everyday tasks and activities.Footnote 1 Footnote 2 Footnote 3 Footnote 4 Footnote 5

Arthritis affects people of all ages. Although it is most prevalent among seniors, arthritis also affects babies, toddlers and people in the prime of their working lives, and can cause lifelong, permanent disability.

At the present time there is no known cure for arthritis, but appropriate treatment and management can prevent disability, maintain function and reduce pain.Footnote 1 Footnote 3 Footnote 4 Footnote 5 While treatments vary according to the type of arthritis, general management and rehabilitation interventions are similar for all types. It includes pain management, self-management education, maintenance of healthy weight, medication and minimization of the impact of arthritis via rehabilitation interventions, such as adapted exercises and the use of assistive devices.

How common is arthritis?

Arthritis is one of the most common chronic health conditions in Canada and a major cause of morbidity, disability and health care utilization.Footnote 2 Footnote 6 Footnote 7

Data from the Canadian Community Health Survey (CCHS) 2007-2008 were used for this chapter.Footnote 1a * The CCHS asked respondents about the presence of chronic conditions with the question "Do you have any of the following long-term conditions that have been diagnosed by a health professional?" "Arthritis, excluding fibromyalgia" was one of the options from which respondents could choose. The CCHS defined a long-term condition as lasting or expected to last six months or longer. Data for people aged 15 years and over were included in this chapter.

Between 2005 and 2007-2008, the wording of the question on arthritis was changed. In 2001, 2003 and 2005, the question included the term "rheumatism", whereas in 2007-2008, this term was removed from the question. Consequently, the estimated prevalence of arthritis cannot be directly compared over time and the estimates presented in this chapter may appear lower than in the previous years. The change in the wording must be taken into account when interpreting and comparing current estimates to those of previous years.

"When I was first diagnosed, I thought, That's it. I'm 34 and life is finished."

— Person living with rheumatoid arthritis

Footnote 1a *
A more detailed description of the CCHS can be found under Data sources at the end of this report. The analyses for this chapter are based on Statistics Canada's CCHS, 2007-2008 share file (unless otherwise specified). All computations on these microdata were done by the Public Health Agency of Canada (PHAC), and the responsibility for the use and interpretation of these data in this report is entirely that of the author(s).

Prevalence by age and sex

In 2007-2008, arthritis as a long-term health condition affected more than 4.2 million Canadians aged 15 years and older — or 16% of this population. Arthritis was the second and third most common chronic condition reported by women and men, respectively (Figure 1-1).

Figure 1-1: Self-reported prevalence of specific chronic conditions by sex, household population aged 15 years and older, Canada, 2007-2008

Figure 1-1 Self-reported prevalence of specific chronic conditions by sex, household

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-1



The prevalence of arthritis increased with increasing age (Figure 1-2). In all age groups, prevalence of arthritis was higher among women than men. Overall, nearly two-thirds (64%) of those affected with arthritis were women, among whom the prevalence was 19%. Prevalence among men was 13%.

Several factors, such as longer life expectancy, hormones and lower socio-economic status, may explain the higher prevalence of arthritis among women.Footnote 8 Footnote 9

Figure 1-2: Self-reported prevalence and number of individuals with arthritis by age and sex, household population aged 15 years and older, Canada, 2007-2008

Figure 1-2 Self-reported prevalence and number of individuals with arthritis

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada.
E – Interpret with caution.

Text Equivalent - Figure 1-2



Although arthritis is perceived as a disease of the elderly, nearly 3 in 5 people (58%) who reported having arthritis in 2007-2008 were younger than 65 years of age (Figure 1-3).

Figure 1-3: Proportion of total number of individuals with arthritis by age group, household population aged 15 years and older, Canada, 2007-2008

Figure 1-3: Proportion of total number of individuals with arthritis, by age group, household population aged 15 years and older, Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-3



Geographic variations in prevalence

This section presents crude and age-standardized prevalence of arthritis by province/territory. It also shows age- standardized prevalence of arthritis by urban/rural areas and health regions. Crude prevalence is defined as the number of events (in this case, the number of people with arthritis) over a specified period of time, divided by the total population. Age – standardization serves to diminish the effect of differences in the age compositions of the various geographic areas and permit direct comparison with the overall Canadian prevalence.

Provinces and Territories

The crude prevalence of arthritis varied considerably across Canada in 2007-2008 (Figure 1-4 and Table 1-2). The highest percentage of individuals who reported having arthritis was found in Nova Scotia (23%), followed by Newfoundland and Labrador (21%), and New Brunswick and Prince Edward Island (20% and 19% respectively). The province of Quebec (12%) and the Territories (Yukon, Northwest Territories and Nunavut) (11%) had the lowest percentage of individuals who reported having arthritis.

Provinces and territories have different age compositions so age-standardized prevalence estimates were calculated to identify if the differences remained after adjusting for these age differences. Newfoundland and Labrador and Nova Scotia were significantly higher (1.1-1.3 times) than the national prevalence, whereas Quebec and British Columbia were significantly lower (0.6-0.9 times) (Table 1-2). This pattern has been consistently reported over time.Footnote 2 Footnote 10 Differences in obesity rates and demographic and socio-economic factors (e.g. variations in ethnic composition, rural/urban, education, income levels, etc) might explain the provincial variations in the prevalence of self-reported arthritis.Footnote 10

Figure 1-4: Crude self-reported prevalence of arthritis, by province/territory, household population aged 15 years and older, Canada, 2007-2008 (see Table 1-2 in the report for data)

Figure 1-4 Crude self-reported prevalence of arthritis, by province/territory, Standardized prevalence significantly lower than national prevalence. Standardized prevalence significantly higher than national prevalence.

Source: Public Health Agency of Canada, using Canadian Community Health Survey, 2007-2008, Statistics Canada and 1991 Census population for age-standardization.

Text Equivalent - Figure 1-4


Table 1-2 Number of individuals, crude and age-standardized prevalence of self-reported arthritis, by province/territory, household population aged 15 years and older, Canada, 2007-2008
Province Number Crude rate (%) Age – standardized rate per 100 population
Source: Public Health Agency of Canada, using Canadian Community Health Survey, 2007-2008, Statistics Canada and 1991 Census population for age-standardization.
British Columbia 560,925 15.7 13.5
Alberta 411,892 14.9 14.8
Saskatchewan 140,658 18.6 15.8
Manitoba 156,349 17.4 15.2
Ontario 1,825,011 17.5 15.7
Quebec 744,037 11.8 9.9
New Brunswick 124,712 20.3 17.0
Nova Scotia 177,515 23.4 19.6
Prince Edward Island 21,592 19.0 16.3
Newfoundland and Labrador 88,929 21.0 17.4
Territories 8,074 11.3 14.2
Canada 4,259,694 16.0 15.3

Text Equivalent - Table 1-2


Urban and rural areas

Both men and women residing in rural areas reported statistically higher rates of arthritis compared to those residing in urban areas (Figure 1-5). In both rural and urban settings, prevalence of arthritis was higher among women than men. The highest prevalence of arthritis was among women living in rural settings (18%). Higher obesity rates and higher (paid or unpaid) work-related injury rates are consistent with the higher prevalence of arthritis among rural Canadians.Footnote 11 Footnote 12 Footnote 13 Footnote 14 Agricultural occupations, such as farming, have been found to be associated with higher prevalence of musculoskeletal conditions, particularly osteoarthritis of the hip and knee.Footnote 12 Footnote 13 Footnote 14

Figure 1-5: Age-standardized self-reported prevalence of arthritis, by rural and urban place of residence and sex, household population aged 15 years and older, Canada 2007-2008

Figure 1-5 Age-standardized self-reported prevalence of arthritis, by rural and urban place of residence and sex, household population aged 15 years and older Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-5



Health regions

The age-standardized prevalence of arthritis varied considerably across Canadian health regions (Figure 1-6). The highest prevalence of arthritis in the country was reported in Ontario's Hastings and Prince Edward counties (27%) and the lowest was reported in Richmond, British Columbia (7%).Footnote 1c * Regional variations in socio-economic status, body mass index and ethnic composition could contribute to the observed variations.Footnote 1

Figure 1-6: Age standardized self-reported prevalence of arthritis, by health regions, household population aged 15 years and older, Canada 2007-2008

Figure 1-6: Age-standardized self-reported prevalence of arthritis (in quartiles), Prevalence of Arthritis 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Footnote 1c *
More details can be found at: Health Profile, October 2011

Text Equivalent - Figure 1-6



Socio-demographic and socio-economic characteristics

Age-standardized prevalence rates are reported in this section. This was done to enable the comparison of rates between groups with different age structure.

The health benefits of relationships like marriage within society are well known.Footnote 51 Footnote 16 For example, married adults are generally found to be healthier than single or divorced adults.Footnote 15 Footnote 16 In keeping with this, the age-standardized prevalence of arthritis was significantly lower among men and women who were married/common law, compared to those who were widowed/separated/divorced (Figure 1-7). The higher rates of arthritis among separated and divorced people could result from the direct effect of arthritis on family dynamics or reduced family income, or from the higher rates of stress-related disability, job loss, and depression among those with arthritis, each of which could put stress on a marriage and lead to separation or divorce.

Figure 1-7: Age-standardized self-reported prevalence of arthritis, by marital status and sex, household population aged 15 years and older, Canada, 2007-2008

Figure 1-7 Age-standardized self-reported prevalence of arthritis, by marital status and sex, household poplation aged 15 years and older Canada 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-7



Ethnicity has been identified as a factor associated with arthritis. The age-standardized prevalence of arthritis for Caucasian, Black, Asian and other ethnic groups is illustrated in Figure 1-8. The prevalence rates of arthritis among people from Asian origins were statistically lower than in people of Caucasian origin.

For information about arthritis among First Nations, Inuit and Métis populations, see Chapter 4.

Figure 1-8: Age-standardized self-reported prevalence of arthritis for Caucasian, Black, Asian and other ethnic groups by sex, household population aged 15 years and over, Canada, 2007-2008

Figure 1-8 Age-standardized self-reported prevalence of arthritis for Caucasian, aged 15 years and over, Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada.
E – interpret with caution.
‘Other’ category – excludes First Nations, Inuit and Metis populations.

Text Equivalent - Figure 1-8



Men and women with less than secondary school education were more likely to report having arthritis compared to all other levels of education (Figure 1-9).

Figure 1-9: Age-standardized self-reported prevalence of arthritis, by level of education and sex, household population aged 15 years and over, Canada 2007-2008

Figure 1-9: Age-standardized self-reported prevalence of arthritis, by level of education and sex, household population aged 15 years and over Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-9



The prevalence of arthritis was significantly higher among women and men with low / low middle income compared to all other income levels (Figure 1-10).

The association between self-reported arthritis and individual level of education and socio-economic status is well established. However, whether arthritis primarily affects those of low socio-economic status or leads to a lower socio-economic status is unknown.Footnote 9 Footnote 17 Footnote 18 These findings may result from differences in the prevalence of risk factors, as a lower socioeconomic status has been linked with inactivity and obesity, both established risk factors for certain types of arthritis. As well, disability associated with arthritis may reduce the opportunities for higher education and employment.

Figure 1-10: Age-standardized self-reported prevalence of arthritis, by income and sex, household population aged 15 years and over, Canada, 2007-2008

Figure 1-10: Age-standardized self-reported prevalence of arthritis, by income and sex, household population aged 15 years and over, Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-10



The age-standardized prevalence of arthritis was significantly lower among immigrants than among people who were Canadian-born (Figure 1-11). This may be partly due to the healthy immigrant effectFootnote 1b*. Women reported a higher prevalence than men in both immigrant (14% versus 9%) and non-immigrant populations (17% versus 12%).

Figure 1-12 illustrates the impact of time since immigration on the prevalence of arthritis among immigrants. The age-standardized prevalence of arthritis was much lower among recent immigrants (less than 15 years since immigration) than those who immigrated 15 years ago or more. The more time since immigration the more similar the prevalence rates of arthritis became to non-immigrant, particularly among women. These findings are consistent with results from the Canadian literature.Footnote 9 Studies reported a narrowing of the health status gap in Canada between individuals who are native born and immigrants as their years in Canada increase — a worsening of immigrant health over time. Some researchers hypothesize that convergence in health outcomes might arise from a process of acculturation, in which recent immigrants gradually take on the characteristics of their "new" society.Footnote 9

Footnote 1b *
The healthy immigrant effect refers to the observation that immigrants are often in superior health to the native-born population when they first arrive in a new country, due to direct or indirect selection effects.

Figure 1-11: Age-standardized self-reported prevalence of arthritis, by immigration status and sex, household population aged 15 years and over, Canada, 2007-2008

Figure 1-11: Age-standardized self-reported prevalence of arthritis, by immigration status and sex, household population aged 15 and over, Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-11



Figure 1-12: Age-standardized self-reported prevalence of arthritis, by time since immigration and sex, household population aged 15 years and over, Canada, 2007-2008

Figure 1-12: Age-standardized self-reported prevalence of arthritis, by time since immigration and sex, household population aged 15 years and over, Canada, 2007-2008

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada
E – interpret with caution.

Text Equivalent - Figure 1-12



Projections of arthritis prevalence

As previously shown (Figure 1-2), the prevalence of arthritis in Canada increases with age. Given the aging of the Canadian population, this pattern has significant implications for the future impact of arthritis in Canada. Canada's population is aging so quickly that in approximately a decade senior citizens will outnumber children.Footnote 19

The prevalence of arthritis is projected to increase by nearly one percentage point every five years over the next quarter century. By 2031, the prevalence of arthritis is projected to be 20% (Table 1-3), which would represent an increase of approximately 38% from 2007. It is estimated that by 2031, 6.7 million Canadians aged 15 years and older will have arthritis, with the largest increases in the older age groups, particularly among those aged 65 years and older due to an increasing number of older people (Figure 1-13). An increase is also noted in the working-age population (35-64 years of age), particularly among those aged 55-64 years.

Table 1-3. ProjectedTable 3 - Footnote * number of individuals aged 15 years and over with arthritis and prevalence of the condition, by sex, Canada, 2007-2031
Year Number of Men with Arthritis Prevalence of Men Number of Women with Arthritis Prevalence of Women Total Number of Men and Women with Arthritis Prevalence of Men and Women

Source: Arthritis Community Research and Evaluation Unit using Canadian Community Health Survey 2007, Statistics Canada.

Table 3 - Footnote *
Based on medium population growth scenario.
2007 1,627,000 12.5% 2,564,000 19.0 % 4,191,000 15.8%
2011 1,838,000 13.1% 2,922,000 20.2 % 4,761,000 16.7%
2016 2,033,000 13.9% 3,218,000 21.2 % 5,251,000 17.6%
2021 2,232,000 14.6% 3,523,000 22.3 % 5,755,000 18.5%
2026 2,427,000 15.4% 3,827,000 23.3 % 6,254,000 19.4%
2031 2,607,000 16.0% 4,116,000 24.2 % 6,723,000 20.2%

Text Equivalent - Table 1-3



While these prevalence projections show similar trends to previously published estimates, a change in the arthritis question in the 2007 CCHS, as compared to previous surveys, resulted in slightly lower overall estimates, as expected.Footnote 2 Furthermore, these projections may, in fact, be conservative due to the assumptions made regarding the stability of the age- and sex-specific prevalence estimates as well as of the prevalence of associated risk factors, such as obesity, over time.

Figure 1-13: Number of people projected to have arthritis, by year and age group, Canada 2007-2031

Figure 1-13: Number of people projected to have arthritis, by year and age group, Canada 2007-2031)

Source: Public Health Agency of Canada using Canadian Community Health Survey, 2007-2008, Statistics Canada

Text Equivalent - Figure 1-13



Summary

  • The word “arthritis” is used to describe more than 100 rheumatic diseases and conditions that affect a joint or joints, causing pain, swelling and stiffness which often lead to disability.
  • Common types of arthritis include osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psori- atic arthritis, systemic lupus erythematosus, gout, and childhood or juvenile idiopathic arthritis.
  • In 2007-2008, over 4.2 million Canadians (16%) aged 15 years and older reported to have arthritis.
  • On the basis of current projections, 1 million more Canadians will have arthritis within 10 years. In 20 years, the prevalence of arthritis may reach one in five Canadians.
  • Close to three in five people (58%) with arthritis are under 65 years. Loss of both work and productivity are frequent and occur early, due to disability. This may impact participation in the labour force.
  • The crude prevalence of arthritis varied considerably across Canada ranging from 23% in Nova Scotia to 12% in Quebec and 11% in the Territories (Yukon, Northwest Territories and Nunavut). Age-standardized prevalence estimates for Newfoundland and Labrador and Nova Scotia were significantly higher (1.1-1.3 times) than the national prevalence whereas, Quebec and British Columbia were significantly lower (0.6-0.9 times). Variations in socio-economic status, body mass index and ethnic composition could contribute to the observed differences between the provinces and territories.
  • Prevalence of arthritis was higher among people who have lower formal education levels and report low income levels.
  • The age-standardized prevalence of arthritis was significantly lower among immigrants compared to Canadian-born people. However, the age- standardized prevalence of arthritis was much lower among recent immigrants (less than 15 years since immigration) than those who immigrated 15 years ago or more. The more time since immigration the more similar the prevalence rates of arthritis became to non-immigrant, particularly among women.

References

Footnote 1
Theis KA, Helmick CG, Hootman JM. Arthritis burden and impact are greater among U.S. women than men: Intervention opportunities. J Women's Health (Larchmt) 2007;16(4):441–53.
Footnote 2
Health Canada. Arthritis in Canada: An Ongoing Challenge. Ottawa, ON: Health Canada, 2003. Catalogue No.: H39-4/14-2003E; ISBN 0-662- 35008-1.
Footnote 3
Arthritis Foundation, Association of State and Territorial Health Officials, Center for Disease Control. National Arthritis Action Plan: A Public Health Strategy. Atlanta, GA: Arthritis Foundation, 1999. URL: www.arthritis.org/naap.php.
Footnote 4
National Arthritis and Musculoskeletal Conditions Advisory Group (NAMSCAG). Evidence to Support the National Action Plan for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis: Opportunities to Improve Health Related Quality of Life and Reduce the Burden of Disease and Disability. Australian Government Department of Health and Ageing: Canberra, Australia, 2004.URL: www.healtyactive.gov.au/internet/main/publishing.nsf/Content/pq-arthritis-evid.
Footnote 5
The Bone and Joint Decade Foundation (BJD), The European League Against Rheumatism (EULAR), The European Federation of National Associations of Orthopaedics and Traumatology (EFORT), and The International Osteoporosis Foundation (IOF). European Action Towards Better Musculoskeletal Health: A Public Health Strategy to Reduce the Burden of Musculoskeletal Conditions—Turning Evidence into Everyday Practice. Bone and Joint Decade, Sweden, 2005. ISBN 91-975284-0-4. URL: www.boneandjointdecade.org/ViewDocument.aspx?ContId=534.
Footnote 6
Perruccio AV, Power JD, Badley EM. The relative impact of 13 chronic conditions across three different outcomes. J Epidemiol Community Health 2007;61(12):1056–61.
Footnote 7
Badley, E. Rheumatic diseases: the unnoticed elephant in the room. J Rheumatol 2008;35(1):6–7.
Footnote 8
Busija L, Hollingsworth B, Buchbinder R, Osborne RH. Role of age, sex, and obesity in the higher prevalence of arthritis among lower socioeconomic groups: a population-based survey. Arthritis Care & Research 2007;57(4):553–61.
Footnote 9
Cañizares M, Power JD, Perrucio AV, Badley EM. Association of regional racial/cultural context and socio-economic status with arthritis in the population: a multilevel analysis. Arthritis Care & Research 2008;59(3):399–407.
Footnote 10
Wang PP, Badley EM. Consistent low prevalence of arthritis in Quebec: findings from a provincial variation study in Canada based on several Canadian population health surveys. J Rheumatol 2003;30(1):126–31.
Footnote 11
Desmeules M, Pong R, Lagacé C, Heng D et al. How healthy are rural Canadians? An assessment of their health status and health determinants. Ottawa: Canadian Institute for Health Information, 2006.
Footnote 12
Kirkhorn S., Greenlee R. T. and Reeser J. C. The epidemiology of agriculture-related osteoarthritis and its impact on cccupational disability. Wisconsin Medical Journal 2003;102, (7): 38–44.
Footnote 13
Holmberg S. et al. Musculoskeletal symptoms among farmers and non-farmers: A population- based study. International Journal of Occupational and Environmental Health 2002;8 339–354.
Footnote 14
Walker-Bone K. and Palmer K. T. Musculoskeletal disorders in farmers and farm workers. Occupational Medicine 2002;52(8): 441–450.
Footnote 15
Kiecolt-Glaser, Newton JK, Tamara L. Marriage and health: His and hers. Psychological Bulletin. 2001;127(4): 472-503.
Footnote 16
Wilson CM, Oswald AJ. How Does Marriage Affect Physical and Psychological Health? A Survey of the Longitudinal Evidence, 2005. IZA Discussion Paper No. 1619. Available at SSRN: ssrn.com/abstract=735205.
Footnote 17
Helmick CG, Lawrence RC, Pollard RA, Lloyd E, Heyse SP. Arthritis and other rheumatic conditions: who is affected now, who will be affected later? National Arthritis Data Workgroup. Arthritis Care & Research 1995;8(4):203–11.
Footnote 18
Callahan LF. Social epidemiology and rheumatic disease. Curr Opin Rheumatol 2003;15(2):110–5.
Footnote 19
Statistics Canada. Population Projections for Canada, Provinces and Territories 2005–2031. Ottawa, ON: Statistics Canada, 2005. Catalogue No.: 91- 520-XIE.

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