Discussions of lifestyle habits as an integral part of care management: a cross-sectional cohort study in patients with established rheumatoid arthritis in Sweden

Participation in cardiovascular screening consultations, the who, when and why - A cohort study on patients with rheumatoid arthritis

BACKGROUND

In accordance with the EULAR recommendations, the Danish Hospital for Rheumatic Diseases have systematically invited patients with rheumatoid arthritis (RA) to cardiovascular (CV) risk assessment since 2011. Patients with high risk are invited to a follow-up screening after one year. To optimize the screening and tailor it to individual needs, information about who accepts vs. declines follow-up is needed. Thus, the aim of this study was to explore participation in systematic CV risk assessment among patients with RA. Furthermore, to explore differences between patients with low vs. high risk, and between patients with high risk who accept vs. decline follow-up.

METHODS

Data from 2,222 outpatients with RA in the period 2011-2021 were retrieved, and of these 1,522 were under 75 years and eligible to be invited. To assess the 10-year risk for CV death, the modified Systematic Coronary Risk Evaluation (mSCORE), derived by multiplying the SCORE by 1.5, was used. Logistic regression analyses were used to explore differences in CV risk factors (triglycerides, HbA1c, lifestyle factors) and measures of disease impact (pain, fatigue, patient global assessment, HAQ, EQ-5D-5L) between patients with low vs. high risk. Differences between high risk patients who accepted vs. declined follow-up were analysed using Wilcoxon rank sum test and chi-squared test for groups.

RESULTS

One thousand one hundred forty-nine received a CV screening invitation and 91 declined participation. Patients with high risk had significantly longer disease duration (OR; 95 CI) (1.017; 1.002-1.032), higher levels of triglycerides (1.834; 1.475-2.280), HbA1C (1.046; 1.020-1.070), pain (1.006; 1.001-1.012), and HAQ-score (1.305; 1.057-1.612) compared to patients with low risk and they more often declined follow-up (43% vs. 28%, p < 0.001). Those who declined a follow-up invitation were older (p = 0.016) and had shorter disease duration (p = 0.006) compared to those who accepted follow-up.

CONCLUSION

A first CV screening consultation was accepted by most patients with RA, while only every other patient with high to very high CV risk adhered to a follow-up screening consultation. Neither measures of disease impact nor lifestyle factors were associated with adherence. Further studies are needed to explore the patients' motivation, barriers and facilitators for adherence or non-adherence to a follow-up consultation.

Diets and Joint Symptoms: A Survey of Moroccan Patients With Chronic Inflammatory Rheumatic Disease

Introduction The role of diet in the onset or aggravation of chronic diseases, especially chronic inflammatory rheumatic disease (CIRD), such as rheumatoid arthritis (RA) or spondyloarthritis (SpA), is a question frequently asked by patients. Our study aims to investigate whether Moroccan patients report a relationship between certain diets and disease symptoms and to study whether patients adopt specific dietary behaviours in order to relieve their symptoms. Methods This is a cross-sectional survey that included all patients followed for CIRD. The questionnaire has three parts, patients' sociodemographic and clinical data, patients' beliefs and attitudes regarding diet in relation to their joint symptoms, and a list of 24 foods for which patients were asked to indicate whether they aggravate, improve, or leave their joint symptoms unchanged. Results Thirty-four percent of the patients reported that the food had an effect on their symptoms, with 25% of them reporting an aggravation. Honey, garlic, and olive oil were the foods most often reported to improve joint symptoms, while red meat, fish, and legumes were most often reported to worsen symptoms. Age and type of rheumatism were factors associated with reporting that food affects joint symptoms. Twenty-three percent of the patients stated that they had already had discussions about diet with their rheumatologists, while 85.7% showed interest in such discussions. Experience with a food that improves joint symptoms was the only factor associated with discussing the diet with a rheumatologist. Conclusion Nearly one-third of the patients with CIRD reported an effect of diet on their joint symptoms.

Healthcare professionals' perceptions of working on lifestyle management for patients with early rheumatoid arthritis - a qualitative study

AIM

To explore HPs' perceptions of working on lifestyle management for patients with early rheumatoid arthritis (RA).

METHODS

In this qualitative study, individual interviews were conducted with 20 HPs. Qualitative content analysis was used, and three categories and six subcategories were identified.

RESULTS

HPs' perceptions of working on lifestyle management for patients with early RA revealed a need for commitment from different levels. This included commitment from healthcare managers and organizations prioritizing work on lifestyle management and providing competence development for HPs. Commitment within the team regarding coordination of interdisciplinary teamwork and development of a structured lifestyle management approach, and commitment to involving patients in lifestyle management, by facilitating patient engagement and a person-centred approach.

CONCLUSIONS

HPs' perceptions of working on lifestyle management for patients with early RA revealed that commitment from healthcare managers, organizations, and the interdisciplinary team was essential to facilitate collaboration, patient involvement, and a person-centred approach.

A combination of two or more unhealthy lifestyle factors is associated with impaired physical and mental health in patients with spondyloarthritis: a cross-sectional study

BACKGROUND

There is increasing knowledge of how individual lifestyle factors affect patients with spondyloarthritis, while studies exploring the combination of unhealthy lifestyle factors are lacking. Thus, our aim was to study the frequency of two or more unhealthy lifestyle factors and their associations with physical and mental health in patients with spondyloarthritis (SpA).

METHODS

A population-based postal survey involving questions on lifestyle factors was completed by 1793 patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), and undifferentiated spondyloarthritis (USpA). Self-reported physical activity, body mass index, and tobacco use were respectively dichotomized as "healthy" or "unhealthy", summarized for each patient and stratified into four groups (0-3; 0 = no unhealthy lifestyle factors). Group comparisons were performed with Chi-squared tests, and associations with physical and mental health outcomes were performed with analysis of covariance and logistic regression analysis.

RESULTS

Out of 1426 patients (52% women) with complete information for all studied lifestyle factors, 43% reported ≥ two unhealthy lifestyle factors-more frequently patients with PsA (48%) than AS (39%) or USpA (38%)-and with no difference between women and men (p = 0.399). Two or more unhealthy lifestyle factors were associated with worse health-related quality of life, disease activity, physical function, pain, fatigue, anxiety, and depression, adjusted for age and SpA-subgroup. If an unhealthy level of physical activity was one of the two unhealthy lifestyle factors, patients reported worse health outcomes.

CONCLUSION

Reporting two or more unhealthy lifestyle factors were associated with worse physical and mental health in patients with SpA. This highlights the need to screen for a combination of unhealthy lifestyle factors and offer individualized coordinated interventions, and tailored coaching to support behavioral change, in order to promote sustainable health.

Patient Empowerment and Associations with Disease Activity and Pain-Related and Lifestyle Factors in Patients With Rheumatoid Arthritis

BACKGROUND

Empowerment is important to patients with rheumatoid arthritis (RA) because most care is in the form of self-management. The aim was to study levels of empowerment and associated variables in patients with RA and to investigate longitudinal clinical data in patients with low and high empowerment.

METHODS

A postal survey was sent in 2017 to patients with RA from the BARFOT (Better Anti-Rheumatic Pharmacotherapy) cohort that included questions about disease activity, pain-related factors, lifestyle habits, and contained the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). The 844 patients who answered the SWE-RES-23 made up the cohort of the present study. Differences in level of empowerment between groups (low, moderate, and high empowerment) were analyzed with ANOVA. Logistic regression analysis was used to study variables associated with low empowerment. Thirdly, we performed comparisons in longitudinal data (15 years) of disease activity, pain, and physical function between the three empowerment groups (low, moderate, and high empowerment).

RESULTS

Patients with low empowerment (n = 282) were significantly older, more often women, and reported worse pain-related factors and physical function and lower moderate and vigorous physical activity compared with those with high empowerment (n = 270). An analysis of longitudinal data found that patients with low empowerment had worse pain and physical function at all time points.

CONCLUSION

Patients with low empowerment have more pain-related symptoms, poorer physical function, and are less physically active. To promote patient empowerment in rehabilitation interventions it is important to identify and support self-management.

Lifestyle factors in patients with rheumatoid arthritis-a cross-sectional study on two Scandinavian cohorts

INTRODUCTION

The risk for cardiovascular diseases and other comorbidities increases with the number of unhealthy lifestyle factors in the general population. However, information on the combined number of unhealthy lifestyle factors in people with rheumatoid arthritis (RA) is scarce.

OBJECTIVES

To study lifestyle factors and the association between disease impact and two or more unhealthy lifestyle factors in two Scandinavian cohorts with RA.

METHODS

We analysed data from two cohorts, Danish (n = 566; mean age 61.82 (SD 11.13) years; 72% women) and Swedish (n = 955; mean age 66.38 (SD 12.90) years; 73% women). Lifestyle factors (tobacco use, BMI, alcohol consumption and physical activity) were dichotomised as healthy vs. unhealthy (range 0-4 unhealthy factors). The association between disease impact and two or more unhealthy lifestyle factors was analysed using logistic regression.

RESULTS

Sixty-six percent of Danish and 47% of Swedish respondents reported two or more unhealthy lifestyle factors, most commonly, being overweight/obese and physical inactivity. For Danish participants, two or more unhealthy lifestyle factors were associated with (OR and 95% CI) male gender (1.86; 1.21-2.85), cardiovascular diseases (1.90; 1.28-2.82) and disease duration (0.97; 0.95-0.99). Corresponding findings for the Swedish cohort were male gender (1.42; 1.07-1.89), pain (1.10; 1.04-1.15), fatigue (1.09; 1.04-1.15), physical functioning (1.64; 1.28-2.10) and quality of life (0.35; 0.20-0.60).

CONCLUSION

Many patients, most often male, in both cohorts had two or more unhealthy lifestyle factors. The number of unhealthy lifestyle factors indicates a multifaceted relationship with disease impact.

Cannabis use assessment and its impact on pain in rheumatologic diseases: a systematic review and meta-analysis

OBJECTIVES

Despite classic analgesic or effective treatments in rheumatic diseases, such as synthetic DMARDs in RA, patients remain in pain and often turn to non-prescribed pharmacological alternatives, such as cannabis self-therapeutic use. However, this medical use of cannabis has not been thoroughly studied.

METHODS

We performed a systematic literature review up to June 2020. The incidence of cannabis consumption was calculated by metaproportion. Differences between cannabis users and non-users were expressed as standardized mean differences using the inverse-variance method. We also assessed the effects of cannabis on pain.

RESULTS

A total of 2900 patients reported cannabis consumption in a sample of 10 873 patients [incidence 40.4% (95% confidence interval (CI): 0.28, 0.54)], and 15.3% (95% CI: 0.07, 0.27) specified that they were currently taking cannabis. Cannabis use was higher in the four fibromyalgia studies [68.2% (95% CI: 0.41, 0.90), n = 611] compared with seven articles concerning RA or lupus [26.0% (95% CI: 0.14, 0.41), n = 8168]. Cannabis consumption was associated with a decrease in pain intensity [VAS pain at baseline 8.2 (2.9) vs 5.6 (3.5) mm over time; pooled effect size -1.75 (95% CI: -2.75, -0.76)]. Cannabis users were younger [58.4 (11.4) vs 63.6 (12.1) years; P <0.001], more often smokers [OR 2.91 (95% CI: 1.84, 4.60)] or unemployed [OR 2.40 (95% CI: 1.31, 4.40)], and had higher pain intensity [5.0 (2.4) vs 4.1(2.6) mm; P <0.001] than non-users.

CONCLUSION

Nearly 20% of patients suffering from rheumatologic diseases actively consume cannabis, with an improvement in pain. The issue of cannabis use in the management of these patients should be addressed during medical consultation, essentially with cannabis-based standardized pharmaceutical products.

From Rheumatoid Factor to Anti-Citrullinated Protein Antibodies and Anti-Carbamylated Protein Antibodies for Diagnosis and Prognosis Prediction in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease mainly involving synovial inflammation and articular bone destruction. RA is a heterogeneous disease with diverse clinical presentations, prognoses and therapeutic responses. Following the first discovery of rheumatoid factors (RFs) 80 years ago, the identification of both anti-citrullinated protein antibodies (ACPAs) and anti-carbamylated protein antibodies (anti-CarP Abs) has greatly facilitated approaches toward RA, especially in the fields of early diagnosis and prognosis prediction of the disease. Although these antibodies share many common features and can function synergistically to promote disease progression, they differ mechanistically and have unique clinical relevance. Specifically, these three RA associating auto-antibodies (autoAbs) all precede the development of RA by years. However, while the current evidence suggests a synergic effect of RF and ACPA in predicting the development of RA and an erosive phenotype, controversies exist regarding the additive value of anti-CarP Abs. In the present review, we critically summarize the characteristics of these autoantibodies and focus on their distinct clinical applications in the early identification, clinical manifestations and prognosis prediction of RA. With the advancement of treatment options in the era of biologics, we also discuss the relevance of these autoantibodies in association with RA patient response to therapy.

Physical activity in established rheumatoid arthritis and variables associated with maintenance of physical activity over a seven-year period - a longitudinal observational study

Background

A large number of patients with RA do not adhere to the recommended levels of physical activity to enhance health. According to EULAR recommendations, physical activity should be part of standard care in people with rheumatic diseases. There have been few larger studies on maintenance of physical activity over longer periods of time. The aim was to study self-reported physical activity levels over 7 years in patients with established rheumatoid arthritis (RA). In addition, to determine variables associated with maintenance or change of physical activity behavior.

Methods

Questionnaires were sent to the BARFOT cohort in 2010 (n = 1525) and in 2017 (n = 1046), and 950 patients responded to both questionnaires. Patients were dichotomized according to meeting MVPA recommendations (physically active at a moderate level ≥ 150 min/week or at an intense level ≥ 75 min/week) or not. Body mass index, smoking habits, tender joint count (TJC), swollen joint count (SJC), Patient Global Assessment (PatGA), pain intensity and distribution, fatigue, physical function (HAQ), health-related quality of life (EQ. 5D), comorbidities, and medical treatment were assessed. We used logistic regression analysis to study variables associated with maintenance and/or change of MVPA behavior.

Results

Forty-one per cent (n = 389) of the patients met MVPA recommendations on both occasions. Patients who met MVPA recommendations over 7 years were younger and a higher proportion were never-smokers. There was a negative association with being overweight or obese, having cardiovascular or pulmonary diseases, pain, fatigue, and physical function, whereas there was a positive association between QoL and maintaining MVPA recommendations. Similar factors were positively associated with a deterioration in physical activity level over time.

Conclusions

Maintenance of physical activity over a long period of time is challenging for patients with established RA. Reports of high quality of life supported maintenance of physical activity while disease related and unhealthy lifestyle factors had a negative effect. Health professionals should consider the patient's standpoint when encouraging maintenance of physical activity, preferably using coordinated lifestyle interventions.

Precision medicine in the care of rheumatoid arthritis: Focus on prediction and prevention of future clinically-apparent disease

There is an emerging understanding that an individual's risk for future rheumatoid arthritis (RA) can be determined using a combination of factors while they are still in a state where clinically-apparent inflammatory arthritis (IA) is not yet present. Indeed, this concept has underpinned several completed and ongoing prevention trials in RA. Importantly, risk factors can be divided into modifiable (e.g. smoking, exercise, dental care and diet) and non-modifiable factors (e.g. genetics, sex, age). In addition, there are now several biomarkers including autoantibodies, inflammatory markers and imaging techniques that are highly predictive of future clinically-apparent IA/RA. Although none of the prevention studies have yet provided major breakthroughs, several of them have provided valuable insights that can help to improve the design of future clinical trials and enable RA prevention. In aggregate, these findings suggest that the most accurate disease prediction models will require the combination of demographic and clinical information, biomarkers and potentially medical imaging data to identify individuals for intervention. This review summarizes some of the key aspects around precision medicine in RA with special focus on disease prediction and prevention.