Is rheumatoid arthritis (RA) preventable? Results of a newly published study suggest that personalized medicine approaches may result in health behavior that may reduce RA risk.
Explore this issueDecember 2017
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“We have gotten to the point where we’ve identified some modifiable behaviors that affect rheumatoid arthritis risk,” says Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine in the Division of Rheumatology, Immunology and Allergy at Brigham and Women’s Hospital in Boston. “We have made a lot of progress in observational studies to identify risk factors for RA, and the next step is trying to target prevention strategies for those at risk.”
Randomized, Controlled Trial
Dr. Sparks, Elizabeth Karlson, MD, MPH, and other colleagues performed a randomized, controlled trial among 238 first-degree relatives of patients with RA.1 Participants were assigned to one of three arms, the Personalized Risk Estimator for RA (PRE-RA) arm, a PRE-RA plus health counseling arm or a comparison arm that received standard RA education.
PRE-RA was an educational intervention adapted from Your Disease Risk. The 78 participants in this arm received a Web-based tool that collected information on demographics, family history and behavioral risk factors, as well as certain genetic variables and the presence of RA-related autoantibodies.
This tool provided educational information personalized for the individual based on their specific risk factors and background. It included a visual presentation of that person’s risks along with specific tips on how to modify their behavioral factors.
The PRE-RA Plus group of 80 subjects also received the tool. They were given an additional 45-minute one-on-one session with a health educator to facilitate interpretation of the results and educate the participant on both their specific risks and risk-related behavioral changes suggested.
The comparison arm consisted of 80 subjects. They received standard education about RA epidemiology, symptoms and diagnosis during a one-on-one session with handouts.
“This study has an innovative design,” says Dr. Sparks. “We built an interactive RA-specific risk calculator giving those first-degree relatives a personalized risk assessment, displaying both relative risk and lifetime risk for RA. We then asked if disclosing this personalized RA risk information would have an impact on their risky behaviors related to RA.”
Subjects completed questionnaires on sociodemographics, risk behavior, concerns, decision-making processes and healthcare utilization at baseline, immediately after the RA educational intervention and then six weeks, six months and 12 months afterward. All received booster education identical to their baseline intervention after completing the six-month follow-up visit.
“We had decided to perform this study among first-degree relatives of those already diagnosed with RA,” says Dr. Sparks. “First off, they are at increased RA risk, probably due to both shared genetics and environmental exposures. Second, we felt they would be motivated to participate because they were familiar with RA and would be amenable to prevention strategies.”
The interventions were chosen based on research into what are important risks in RA development. These included smoking, fish omega-3 fatty acid intake, poor dental health behaviors and being overweight or obese. With the exception of the fish and omega-3 fatty acids, all of these behaviors increase risk.
The primary outcome was readiness for change. This was based on the transtheoretical model for behavior change levels measured using validated contemplation ladder scales. An increase in motivation to improve any risk behaviors (smoking, diet, exercise or dental hygiene) was found when there was an increase in any of the corresponding ladder scores when compared with baseline, at six weeks and six months after the intervention.
PRE-RA Increased Ladder Scores
Those randomized to receive PRE-RA (either alone or with the health educator) were more likely to increase their ladder scores over post-intervention assessments than those randomized to the general RA education arm (RR 1.23, 95% confidence interval [CI] 1.01–1.51).
By six months, 63.9% of those receiving PRE-RA and 50.0% of the comparison group increased their motivation to improve behaviors (age-adjusted difference 15.8%, 95% CI 2.8–28.8%). When compared with nonpersonalized education, more PRE-RA participants increased fish intake (45.0% vs. 22.1%; P=0.005), brushed more often (40.7% vs. 22.9%; P=0.01), flossed with increased frequency (55.7% vs. 34.8%; P=0.004) and quit smoking (62.5% vs. 0.0% among 11 smokers; P=0.18).
Those in the PRE-RA Plus group were more likely to report increased tooth brushing (P=0.025), flossing (P=0.010) and fish consumption (P=0.009) at six months compared with the comparison arm. There were no statistically significant differences in behavior changes between the two PRE-RA arms suggesting that the Web-based PRE-RA tool by itself could be a powerful tool if widely implemented.
Motivated to Change Following Education
“What we found is that, overall, people are motivated to change those behaviors once they were educated about them using this novel, personalized RA risk calculator,” says Dr. Sparks. “Just the act of giving this RA risk calculator to first-degree relatives made them want to change those behaviors more than those that were receiving standard care in the comparison arm.”
The results in smokers particularly caught Dr. Sparks’ attention. Although not statistically significant due to the low number of smokers in the study, more than half of those who smoked in the PRE-RA group quit smoking during the study. This was in stark contrast to not a single person giving up smoking in the non-intervention group.
“For smoking, we thought this was a pretty powerful intervention,” he says. “It is typically very hard to convince people to give up smoking and more than half [of the group who] received PRE-RA had quit smoking six months after the intervention.”
The researchers noted that their findings may be applicable only to first-degree relatives of those with RA and not necessarily at risk for other chronic diseases. They also say that because the PRE-RA tool was adapted from a website developed to calculate personalized risk for other chronic conditions, a similar framework is likely to be relevant to other diseases, particularly because diet, smoking and obesity have an impact on many other illnesses.
Behavioral factors may be the only potentially modifiable risks for RA. Evidence that they can be changed could be a catalyst to larger intervention trials powered to find the specific effect of behaviors on actual RA risk or surrogate biomarkers.
Subjects were recruited at a single site and were mostly well-educated women, which may limit generalizability to other groups. Although the researchers performed a randomized, controlled trial, they were unable to blind subjects to the intervention they received due to its nature. It is possible that lack of blinding may have biased the outcome.
“In practice, we know there are behaviors related to RA risk,” says Dr. Sparks. “We have shown that telling people about their risk for RA really does change behaviors—and for the better. Although this doesn’t directly address whether these interventions change a person’s risk, we know these are healthy behaviors from many aspects.”
Kurt Ullman has been a freelance writer for more than 30 years and a contributing writer to The Rheumatologist for 10 years.
- Sparks JA, Iversen MD, Yu Z, et al. Disclosure of personalized rheumatoid arthritis risk using genetics, biomarkers, and lifestyle factors to motivate health behavior improvements: A randomized controlled trial. Arthritis Care Res. 2017 (in press).