A personalized medicine approach that translates epidemiologic findings about genetics, biomarkers, and behavior into a personal, web-based intervention appeared to help people reduce their risk of rheumatoid arthritis (RA), according to new research from Brigham and Women’s Hospital and Harvard Medical School in Boston.
First-degree relatives of RA patients who received personalized disclosure and education about RA were 23% more likely to increase their motivation to improve risk-related behaviors over 6 months compared with those who received standard, non-personalized education (RR 1.23, 95% CI 1.01-1.51, P=0.043), reported Jeffrey Sparks, MD, MMSc, and colleagues, writing online in Arthritis Care and Research.
Compared with those who received standard RA education, relatives who received personalized information reported increasing their fish intake (45% versus 22.1%, P=0.005), brushing their teeth more frequently (40.7% versus 22.9%, P=0.01), flossing more frequently (55.7% versus 34.8%, P=0.004), and quitting smoking (62.5% versus 0.0% among 11 smokers, P=0.18). Individuals with the highest lifetime RA risk were most motivated to improve behavior, despite learning about non-modifiable factors like age, sex, genetics, and autoantibodies.
“Genetic risk disclosure alone has had limited impact on other health behavior changes,” the team wrote. “Our study is one of the few to evaluate the effect of factors beyond genetics by including the impact of biomarkers, demographics, and behavioral risk factors to motivate positive health behaviors changes.”
Having a first-degree relative with RA increases personal RA risk by four times, and while both genetic and behavioral RA risk factors are shared within families, choice plays an important role. “The population attributable risk for RA of known behavioral factors is about 40%, suggesting that improving these health behaviors may reduce risk of developing RA. Intention to change behavior is the first step toward persistent behavior change, which may subsequently lead to demonstrable effects on health outcomes such as autoantibody development or RA risk.”
In this proof-of-concept trial, the researchers recruited unaffected parents, children, and siblings of RA patients at Brigham and Women’s Hospital from 2013 to 2016. Excluded were relatives who were older than age 70 or who had symptoms or a diagnosis of any systemic rheumatic disease.
The investigators incorporated a Personalized Risk Estimator for RA (PRE-RA) into the study, a web-based tool they had previously designed to disclose personalized RA risk based on genetics, biomarkers, demographics, and risk-related behavior. Four behavioral factors were included in the RA risk estimate: cigarette smoking, excess body weight, poor oral health, and low fish intake. The tool showed participants their genetic (HLA-DRB1) and autoantibody (rheumatoid factor and cyclic citrullinated peptide) results, presented relative and absolute lifetime risk of RA, and provided personalized education to modify behavior.
Participants were randomized to one of three groups:
- The comparison arm (n=80) received non-personalized, standard education about RA epidemiology, symptoms, and diagnosis
- The PRE-RA arm (n=78) received the web-based PRE-RA risk disclosure and education tool
- The PRE-RA Plus arm (n=80) received the PRE-RA tool plus a 45-minute session with a health educator who helped interpret findings and taught participants about changing risk-related behavior
Most participants were female (76.5%), white (87.0%), and had greater than high school education (87.8%). Mean age was 43.4 in the comparison group and 46.7 in the PRE-RA groups.
The primary outcome was readiness for change in four areas associated with RA risk — smoking, diet, exercise, and dental hygiene — using the transtheoretical model (TTM) of behavior change. TTM, a tool developed by James Prochaska, PhD, director of the Cancer Prevention Resource Center at the University of Rhode Island, assesses how ready an individual is to make healthier choices. The tool includes a contemplation ladder with rungs corresponding to stages of motivation progressing through pre-contemplation, contemplation, preparation, action, and maintenance, and was validated originally in studies of behavioral changes in smokers.
Sparks and colleagues defined increased motivation to improve as an increase in any ladder score compared with baseline. The team also evaluated self-reported changes in RA risk-related behaviors as secondary outcomes.
For the primary analysis, the researchers combined the two PRE-RA arms into a single group (n=158). Over three time points — immediately, 6 weeks, and 6 months after intervention — those in the PRE-RA group were more likely to increase motivation to improve behavior than those in the comparison arm (age-adjusted RR 1.23, 95% CI 1.01-1.51, P=0.043).
Individuals in the PRE-RA group were also more likely to have ≥1 point increase in the dental hygiene ladder than those in the comparison group (26.3% versus 14.1%; age adjusted difference of 12.6%, 95% CI 2.6-22.5%, P=0.014). The proportion of participants who had an increase in diet and exercise ladders was similar between the PRE-RA group and the comparison arm.
At 6 months post-intervention, more individuals in the PRE-RA group reported brushing and flossing teeth more frequently, increasing fish intake, and stopping smoking than those in the comparison group. At all time points, the web-based PRE-RA tool performed similarly well with or without a health educator.
These results provide a rationale for larger studies evaluating the effect of behavior changes on clinical outcomes like autoantibody production or RA development, the researchers said
Regarding study limitations, Sparks and colleagues said that due to the trial’s nature, it was not possible to blind the participants to their educational intervention. In addition, since most of the participants were well-educated women, the results might not be generalizable to other populations. Furthermore, the outcomes were self-reported, so participants actually might not have improved behaviors.
This research was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
No conflicts of interest were noted
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner