Reviewed by Dr. Lauren Smith
Sparks J, et al. Arthritis Care Res. 2017 Oct 12; Epub ahead of print

SUMMARY
At present time, there is evidence for various risk factors (some modifiable) for rheumatoid arthritis (RA) including HLA-DRB1, smoking, obesity, low fish intake and poor dental health. However, prior studies have shown that disclosure of personalized genetic risk alone did not motivate individuals to improve health behaviors. This study aims to evaluate changes in health behaviors of first-degree relatives (FDRs) without RA after disclosure of personalized RA risk comprised of both genetic and lifestyle factors compared to receiving standard RA education. Of the 238 subjects enrolled, 158 were randomized to the intervention arms that included a novel web based tool that disclosed individuals’ RA risk with regards to their genetics, biomarkers, demographics and RA risk-related behaviors (PRE-RA). The PRE-RA group was further divided into two groups. One group received an additional one-on-one session with a health educator (PRE-RA+, n=80) to help interpret and provide personalized education regarding potential risk related RA behaviors and the remaining (n=78) received the web based tool. The control group (n=80) received standard RA education.
 All participants were screened for past or current inflammatory arthritis or other rheumatic diseases and were excluded if present. At 6 weeks, 6 months and 12 months after the intervention individuals completed questionnaires on sociodemographic data, risk behavior and health care utilization. The primary outcome was to assess motivation to change and self-reported changes in four RA related behaviors that included physical activity, food intake, tooth brushing/flossing and smoking (only for current smokers). Subjects motivation for lifestyle adjustment was assessed using validated contemplation ladder scales (score 0-10, higher numbers equated to increased motivation to change). These scaled are based on a five-stage developmental sequence of behavior change: pre-contemplation, contemplation, preparation, action, and maintenance.

Results at 6 months showed 64% of the PRE-RA arm increased motivation to change RA related behaviors whereas the control arm saw similar improvement in only 50% of individuals (p=0.017). This difference was most significant with regards to dental hygiene with the control arm improving in 14.1% of people but in 26.3% of the PRE-RA group (p=0.014). No statistically significant difference was found with food intake, physical activity or smoking. However, there were few smokers at baseline and several participants in the intervention arm quit smoking compared to none in the control arm. Similar results were seen at 12 months. A secondary analysis comparing the two PRE-RA groups showed no difference in behaviors between subjects who received the additional health educator session. Moreover, subjects who had a high lifetime risk to develop RA (as indicated on the web based tool) were more likely to improve on all outcomes as compared to the control arm (p=0.004). In contrast, those with low lifetime risk showed no difference in primary outcomes (p=0.32).

COMMENTARY
This study highlights that disclosing personalized chronic disease risk assessments to individuals can motivate them to make healthier life choices which may reduce their chance of developing a disease. Several limitations included: the study was conducted at a single center where the demographics of the participants were not diverse (most were female [76%], white [87%] and highly educated [88% had greater than high school diploma]), therefore, these results may not be generalizable to other populations/ centers. Study participants were selected based on FDRs with RA so these results may not be generalizable to other rheumatic diseases. Additionally, the behaviors were self-reported so there may be some degree of recall bias. Since persons with the highest overall risk for developing RA made changes in every possible behavioral category, this trial is a positive indicator that disclosure of health risks in a personalized manner can improve health behaviors. Overall, more research is needed with a more diverse participant pool to see how these results may apply to a broader population and how improving health behaviors translates into a change in disease incidence, severity or outcomes.

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