Lifestyle, cardiovascular screening and health in patients who have rheumatoid arthritis

Julie Katrine Karstensen*

*Corresponding author for this work

Research output: ThesisPh.D. thesis

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Abstract

Background: The risk of cardiovascular diseases (CVDs) in individuals who have been diagnosed with rheumatoid arthritis (RA) is double that of the general population. For disease prevention purposes, the European Alliance of Associations for Rheumatology (EULAR) recommends systematic cardiovascular (CV) screening and adherence to a healthy lifestyle, which includes healthy eating habits, refraining from smoking, limiting alcohol consumption and engaging in health-promoting physical activities. Having two or more unhealthy lifestyle factors increases the risk for CVDs in the general population. Yet, there exists a knowledge gap about the combined number of unhealthy lifestyle factors among individuals who have RA, and their collective impact on overall health. Additionally, there is a need for a better understanding of the engagement in and perspectives of patients participating in systematic CV screening consultations. The overall aim of this PhD project was thus to study the lifestyle factors and adherence to CV screening consultations in patients who have RA.

Methods: This PhD study used an explanatory sequential mixed-method design that included two quantitative and one qualitative study. Study 1 was a cross-sectional study, where the combined number of unhealthy lifestyle factors and the possible association to measures of disease impact was studied in a Danish and a Swedish cohort of patients who have RA. Study 2 was also a cross-sectional study and included the Danish cohort of patients who have RA, exploring participation in a CV screening consultation. Furthermore, the differences between patients with low to moderate (<5%) versus high to very high (≥5%) risk for CV death within 10 years and differences in participation in a follow-up screening among patients with high to very high CV risk, were also explored. Logistic regression analysis was used in study 1 and 2. Findings from the quantitative studies were integrated in the qualitative study (Study 3) at the design and method level to inform the interview guide and to identify patients that should be invited to participate in Study 3. In Study 3, semi-structured individual interviews explored patients’ perspectives on adherence to CV screening and lifestyle changes. Data were analysed using a qualitative content analysis that was inspired by Graneheim and Lundman. Using a narrative approach, the results and further implications from the three studies were integrated in the Discussion section.

Results: Study 1 included 566 patients who have RA from a Danish cohort and 955 patients who have RA from a Swedish cohort. In total, 66% of the Danish cohort and 47% of the Swedish cohort reported two or more unhealthy lifestyle factors. In the two cohorts, men had an increased risk of having two or more unhealthy lifestyle factors compared with women and the two most commonly reported lifestyle factors were physical inactivity and being overweight or obese. In both cohorts patients who reported two or more unhealthy lifestyle factors more often reported having CVDs compared to those who had less than two unhealthy lifestyle factors. Additional findings in the Danish cohort were shorter disease duration among those who had two or more unhealthy lifestyle factors compared to those who had less than two unhealthy lifestyle factors. In the Swedish cohort, the additional findings included a higher swollen joint count, worse global health, pain, fatigue and physical disability, as well as a lower health-related quality of life score for those who had two or more unhealthy lifestyle factors, compared with those who had less than two unhealthy lifestyle factors.

Study 2, included 2,222 patients who have RA. Of these, 1,149 patients were invited to a CV screening and 91 patients declined participation. Patients with a high to very high CV risk had a longer disease duration, higher levels of triglyceride and long-term glucosis and reported worse pain and physical disability than those who had a low to moderate risk. In addition, patients with high to very high CV risk more often reported having two or more unhealthy lifestyle factors compared to those with low to moderate risk. Furthermore, patients categorised as high to very high CV risk more often declined participation in a follow-up CV screening than those with low to moderate risk. Among the high to very high risk patients who declined a follow-up consultation, the tendency was that they were older and had a shorter disease duration compared to the high to very high risk patients who accepted a follow-up consultation.

Study 3 included 16 patients who had been diagnosed with RA and had participated in at least one CV screening. The analysis derived two main themes, each comprising two sub-themes. The first main theme was ‘Accepting an offer’, which encompassed the sub-themes of ‘Engagement in the screening consultation’ and ‘Risk Awareness’. The second main theme was ‘Living with a chronic disease and embracing changes’, which was described through the sub-themes of ‘Motivation for lifestyle changes’ and ‘Strategies to achieve lifestyle changes’.

Conclusion: Every second patient with RA had two or more unhealthy lifestyle factors, with this occurrence being more common in men than in women and in patients with CVDs, underscoring the necessity for disease prevention programmes. The number of unhealthy lifestyle factors did not consistently correlate with measures of disease impact, highlighting the complex relationship between lifestyle factors and health. Implementing lifestyle changes can be challenging, especially when multiple habits require modification. Insights from the interviews revealed that patients who embraced lifestyle changes were motivated and had developed strategies to support these changes, with social networks playing a crucial role in initiating and maintaining a healthier lifestyle. In the context of a rheumatology clinic, most patients with RA accepted the initial CV screening invitation, but only every second patient with high to very high CV risk adhered to a follow-up screening. Motivations for participating in CV screenings varied, encompassing considerations of preventive measures and personal benefits. These screenings heightened patients’ awareness of their CV risk and the significance of lifestyle modifications. In summary, these findings highlights the importance of integrated healthcare strategies, incorporating individualised approaches and tailored guidance and support, to manage the intricate interplay between RA, CV risk, and adherence to a healthy lifestyle.
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
Supervisors/Advisors
  • Bremander, Ann, Principal supervisor
  • Primdahl, Jette, Co-supervisor
  • Christensen, Jeanette Reffstrup, Co-supervisor
Date of defence19. Jun 2024
Publisher
DOIs
Publication statusPublished - 6. Jun 2024

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