OPEN Research Support

ph.d. student
Julie Katrine Karstensen
Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark

Projekt styring
Projekt status    Sampling ongoing
Data indsamlingsdatoer
Start 15.01.2020  
Slut 31.12.2027  

Lifestyle habits and screening for cardio-vascular risk factors in patients with rheumatoid arthritis - from register to the patient's perspective

Short summary

Patients with rheumatoid arthritis (RA) have an increased risk for cardio-vascular diseases (CVD), why screening for CVD and adhering to a healthy lifestyle are recommended. In the general population, unhealthy lifestyle habits affect Quality of Life (QoL) and the combination of two or more unhealthy lifestyle habits increases the risk of morbidity as well as mortality. However, this is scarcely studied in patients with RA. Therefore, the overall aim of this PhD project is to study the prevalence of a combined number of unhealthy lifestyle habits and their associations to QoL and the risk for CVD among patients with RA. Also, to explore barriers and facilitators for lifestyle changes among patients with RA. 


In industrialised countries approximately 0.5-1.0% of the adult population are diagnosed with rheumatoid arthritis (RA), where the Nordic countries are among those with the highest prevalence. RA is associated with an increased risk for comorbidities, and some of these are associated with unhealthy lifestyle habits. Lifestyle habits such as smoking, unhealthy diet, extensive alcohol use and not reaching recommendations for health enhancing physical activity are of importance for the occurrence of comorbidities such as cardiovascular diseases (CVD), diabetes and some forms of cancer in the general population. These lifestyle habits are all modifiable risk factors that can affect health and quality of life. The combination of two or more unhealthy lifestyle habits increases the risk of morbidity as well as mortality in the general population, why the combined effect of unhealthy lifestyle habits is of great interest. 

Compared with the general population, patients with RA have an increased risk of CVD, why screening consultation are recommended. The European League Against Rheumatism (EULAR) has published recommendations for cardiovascular risk management for patients with RA. Identified risks should be managed according to national guidelines and the patients risk for CVD should be scored using the Systematic Coronary Risk Evaluation (SCORE), unless national guidelines recommend other scoring systems. In the SCORE risk chart, traditional risk factors such as age, gender, smoking status, systolic blood pressure and total cholesterol/high-density lipoprotein (HDL) cholesterol ratio are integrated. A SCORE <5% is considered as low-to-moderate risk, a SCORE >= 5% and <10 is considered high risk and a SCORE of >=10% as very high risk for cardiovascular death within 10 years. It is recommended to multiply the risk SCORE with 1.5 in patients with RA for a more accurate risk prediction. It is emphasised that all lifestyle recommendations for patients with RA should highlight the benefits of smoking cessation, regular physical activity and a healthy diet, but the combined effect of these unhealthy lifestyle habits are not accounted for in the risk SCORE. The Danish Hospital for Rheumatic diseases, has developed a clinical guideline for CVD screening of all outpatients with RA <=75 years of age, based on the EULAR recommendations and national guidelines. The SCORE risk chart is applied, together with a dialogue regarding lifestyle habits (including measuring waist circumference and BMI). The patient's priorities, possible support and barriers in everyday life to make changes regarding their lifestyle habits are explored. In agreement with the EULAR recommendations, patients under the age of 70 with a risk score of >= 5% are invited to a follow-up screening consultation after 12 months. Patients with high risk include those with known CVD or diabetes mellitus. Information is scarce concerning patients' perception and experiences from participating in a CVD screening consultation. In addition, there is a lack of knowledge why high risk patients with RA, accept or decline repeated follow-up screening consultations. Furthermore, additional information is needed regarding barriers and facilitators to lifestyle changes for patients with RA.

The aim of this PhD project is

- To study the prevalence of a combined number of unhealthy lifestyle factors and their association to Health Related Quality of Life in patients with RA (Study 1). 

- To study the prevalence of unhealthy lifestyle habits in patients with an increased risk of CVD according to the risk SCORE (Study 2). 

- To explore the patient's perspective on participating in screening consultations, barriers and facilitators to lifestyle changes will also be studied (Study 3)

Description of the cohort

Study 1: The first study in this project is a collaboration between Denmark and Sweden, based on register data from two separate RA cohorts. The Danish cohort consist of approximately 1000 patients diagnosed with RA, who have participated in a CVD screening at Danish Hospital for Rheumatic Diseases in the period 01 January 2016 to 31 December 2018. The Swedish BARFOT cohort (the Better Anti-Rheumatic Pharmacotherapy) consist of 1046 patients diagnosed with RA who answered a questionnaire including questions about lifestyle habits in 2017. The Swedish data will be stored and analyzed in Sweden.

Study 2: The same data from the DANBIO registry as in study 1. However, patients over the age of 70 years is excluded as they only received one CVD screening consultation and the risk SCORE only applies to persons <70 years. 

Study 3: Approximately 20 patients with RA aged <70 with a high or very high risk for cardiovascular death within 10 years according to the risk SCORE. Furthermore, only patients who have participated or declined a follow-up CVD screening consultation at the Danish Hospital for Rheumatic Diseases will be included in the study.  

Data and biological material

Danish patients are self-reported or physician-reported from the DANBIO database 2016-2018. No new data will be collected.

In study 1 and 2 in this project we use registry data. Danish data will be retrieved from a cohort of outpatients with RA from the Danish Hospital for Rheumatic registered in DANBIO, a national Danish registry for all patients with an inflammatory joint disease. 

The following will be extracted:

• Information about lifestyle habits (Smoking, Alcohol use, Physical activity,)

• Anthropometric measurements (Height, Weight, Waist circumference)

• Information on vital signs (Blood pressure)

• Demographic information (Age, Gender) 

• Socioeconomic factors (Marital status, Education) 

• Information on Health Related Quality of life (Measured with EQ-5D)

• Information on treatment (Medication)

• Information on disease related factors (i.e. Disease duration, Disease activity, Fatigue, Pain)

• Comorbidities 

• Blood test results (i.e. Fasting glucose, Triglycerides, Total cholesterol, High density cholesterol, Low density lipoprotein cholesterol levels)

In study 3, we use individual interviews to explore patients with RAs experience regarding the screening consultation, barriers and facilitators towards lifestyle changes and their reasons for accepting or declining a follow-up screening consultation after 12 months.   

Collaborating researchers and departments

Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark and Clinical Sciences, Department of rheumatology, Lund University, Lund, Sweden. Professor in Rheumatology rehabilitation, PT, PhD, Ann Bremander (main supervisor).

Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark, Hospital Sønderjylland, University Hospital of Southern Denmark, Aabenraa, Denmark and Department of Regional Health Research, University of Southern Denmark, Odense, Denmark. Professor in Rheumatology rehabilitation, RN, PhD, Jette Primdahl (co-supervisor). 

Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark. Associate Professor, OT, PhD, Jeanette Reffstrup Christensen (co-supervisor).