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In the last decade, studies into sedentary behaviour in inflammatory arthritis have raised important questions regarding its role in this condition. Specifically, evidence is needed on whether sedentary behaviour might exacerbate adverse inflammatory arthritis outcomes, and whether reducing sedentary behaviour might offer an effective avenue for self-management in this population. Research exploring these important research questions is still very much in its infancy and lacks the direction and scientific rigour required to inform effective intervention design, delivery and evaluation. Behavioural epidemiology refers to research that aims explicitly to understand and influence health behaviour patterns to prevent disease and improve health. To this end, the Behavioural Epidemiology Framework specifies a focused approach to health behaviour research, which leads to the development of evidence-based interventions directed at specific populations. In this review, we introduce the Behavioural Epidemiology Framework in the context of research into sedentary behaviour in inflammatory arthritis and ask: where are we, and where do we need to go?, (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Objectives: The aims of this study were to examine the longitudinal and bi-directional associations of pain and fatigue with sedentary, standing and stepping time in RA., Methods: People living with RA undertook identical assessments at baseline (T1, n = 104) and 6-month follow-up (T2, n = 54). Participants completed physical measures (e.g. height, weight, BMI) and routine clinical assessments to characterize RA disease activity (DAS-28). Participants also completed questionnaires to assess physical function (HAQ), pain (McGill Pain Questionnaire) and fatigue (Multidimensional Assessment of Fatigue Scale). Participants' free-living sedentary, standing and stepping time (min/day) were assessed over 7 days using the activPAL3µ™. For the statistical analysis, hierarchical regression analysis was employed to inform the construction of path models, which were subsequently used to examine bi-directional associations of pain and fatigue with sedentary, standing and stepping time. Specifically, where significant associations were observed in longitudinal regression analysis, the bi-directionality of these associations was further investigated via path analysis. For regression analysis, bootstrapping was applied to regression models to account for non-normally distributed data, with significance confirmed using 95% CIs. Where variables were normally distributed, parametric, non-bootstrapped statistics were also examined (significance confirmed via β coefficients, with P < 0.05) to ensure all plausible bi-directional associations were examined in path analysis., Results: Longitudinal bootstrapped regression analysis indicated that from T1 to T2, change in pain, but not fatigue, was positively associated with change in sedentary time. In addition, change in pain and fatigue were negatively related to change in standing time. Longitudinal non-bootstrapped regression analysis demonstrated a significant positive association between change in fatigue with change in sedentary time. Path analysis supported the hypothesized bi-directionality of associations between change in pain and fatigue with change in sedentary time (pain, β = 0.38; fatigue, β = 0.44) and standing time (pain, β = -0.39; fatigue, β = -0.50)., Conclusion: Findings suggest pain and fatigue are longitudinally and bi-directionally associated with sedentary and standing time in RA., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Physical inactivity is prevalent in rheumatoid arthritis (RA) patients, increasing the risk of poor physical health and compromised well-being. Interventions are therefore required to support physical activity (PA) behavior change in this population. This study examined whether a self-determination theory (SDT) based exercise intervention for people with RA, increased autonomous motivation for PA and in turn, moderate-to-vigorous PA (MVPA) and subjective vitality RA patients (n = 115) were randomized to a 3-month SDT-based psychological intervention + RA-tailored exercise program (experimental group, n = 59) or a RA-tailored exercise program only (control group, n = 56). During the program, the SDT-based intervention group received one-on-one consultations with a PA advisor trained in delivering strategies to promote autonomous motivation for PA. Well-established questionnaires assessed autonomous and controlled motivation for PA, MVPA (min/week), and subjective vitality at baseline (T1) and 3 months (T2). Path analysis examined the hypothesized theoretical process model. The model demonstrated an excellent fit to the data (n = 70, χ2 (26) = 28.69, p = .33, comparative fit index = 0.99, root square mean error of approximation = 0.04). The intervention corresponded to higher autonomous motivation and lower controlled motivation for PA at T2, after controlling for T1 autonomous and controlled motivation. In turn, changes in autonomous motivation from T1 to T2 significantly positively predicted changes in MVPA and subjective vitality. Results suggest an SDT based psychological intervention comprising autonomy-supportive strategies for PA predicted greater reported autonomous reasons for PA in RA patients participating in a tailored 3-month exercise program. Increased autonomous motivation linked to increased engagement in MVPA and feelings of vitality in these patients., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

RA is a chronic autoimmune disease characterized by high grade-inflammation, and associated with elevated cardiovascular risk, rheumatoid-cachexia and functional impairment. Sedentary behaviour (SB) is linked to heightened inflammation, and is highly pervasive in RA, likely as a result of compromised physical function and persistent fatigue. This high sedentarity may exacerbate the inflammatory process in RA, and hold relevance for disease-related outcomes. The aim of this narrative review is to provide an overview of the definition, measurement and health relevance of SB in the context of RA. Contradictions are highlighted with regard to the manner in which SB is operationalized, and the significance of SB for disease outcomes in RA is outlined. The advantages and disadvantages of SB measurement approaches are also discussed. Against this background, we summarize studies that have reported SB and its health correlates in RA, and propose directions for future research., (© The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

This study aimed to determine the physical activity levels and awareness of the influence of physical activity and overweight/obesity on breast cancer risk among NHS breast screening programme (NHSBSP) attendees. One hundred and eighty-eight (white British = 95%; post-menopausal = 80%) attendees completed a demographic and anthropometric data questionnaire, International Physical Activity Questionnaire (IPAQ) and awareness of breast cancer risk factors questionnaire. IPAQ data were reported as continuous measures (MET-min · week(-1)) and as categorical variables (low, moderate and high activities). The highest median physical activity levels were reported in the domestic physical activity domain (756 MET-min · week(-1)). Most participants were categorized as 'moderately active' (45%), while 30% were classified in the 'high activity' and 25% as 'low activity' categories. Almost a third of participants (30%) reported no leisure-time physical activity and 83% reported no vigorous physical activity. There was high awareness of the effects of physical activity (75%) and obesity (80%) on breast cancer risk. No significant differences were found between physical activity categories and awareness that physical activity can reduce breast cancer risk (p > 0.05). However, compared with moderate and high activity categories, participants in the 'low activity' category were significantly more likely to respond that they thought they achieved recommended physical activity levels (p < 0.05). Participants who are unaware of their inadequate physical activity levels may have a less positive intention to increase physical activity levels. Practical strategies aimed to increase knowledge of the recommended physical activity guidelines and facilitate the achievement of these guidelines may be required for NHSBSP attendees., (© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: The aim of this study was to investigate the association of different physical fitness levels [assessed by the maximal oxygen uptake (VO2max) test] with cardiovascular disease (CVD) risk factors in patients with RA., Methods: A total of 150 RA patients were assessed for cardiorespiratory fitness with a VO2max test and, based on this, were split in three groups using the 33rd (18.1 ml/kg/min) and 66th (22.4 ml/kg/min) centiles. Classical and novel CVD risk factors [blood pressure, body fat, insulin resistance, cholesterol, triglycerides, high-density lipoprotein (HDL), physical activity, CRP, fibrinogen and white cell count], 10-year CVD risk, disease activity (DAS28) and severity (HAQ) were assessed in all cases., Results: Mean VO2max for all RA patients was 20.9 (s.d. 5.7) ml/kg/min. The 10-year CVD risk (P = 0.003), systolic blood pressure (P = 0.039), HDL (P = 0.017), insulin resistance and body fat (both at P < 0.001), CRP (P = 0.005), white blood cell count (P = 0.015) and fibrinogen (P < 0.001) were significantly different between the VO2max tertiles favouring the group with the higher VO2max levels. In multivariate analyses of variance, VO2max was significantly associated with body fat (P < 0.001), HDL (P = 0.007), insulin resistance (P < 0.003) and 10-year CVD risk (P < 0.001), even after adjustment for DAS28, HAQ and physical activity., Conclusion: VO2max levels are alarmingly low in RA patients. Higher levels of VO2max are associated with a better cardiovascular profile in this population. Future studies need to focus on developing effective behavioural interventions to improve cardiorespiratory fitness in RA., (© The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: RA associates with an increased rate of sudden cardiac death (SCD). A prolonged QTc interval has been associated with arrhythmogenic and SCD in patients with long QT syndrome. Despite the previously reported contemporary association of CRP with SCD, thus far no studies have examined the association of QTc with mortality in RA, a condition characterized by high inflammatory burden. The aim of this study was to examine the role of electrocardiography (QT corrected interval) in predicting all-cause mortality in patients with RA who have an increased rate of SCD and a high inflammatory burden., Methods: Three hundred and fifty-seven RA patients with detailed baseline clinical characterization and 12-lead ECGs were followed up for a mean of 73.0 (S.D. 18.3) months. Linear and Cox regression analyses were used to identify variables that associate with QTc and examine its association with all-cause mortality., Results: The patients' mean age was 60.6 (S.D. 12.0) years, 267 (74.8%) were females and 54 (15.1%) died during the follow-up period. Age (β = 0.231, P < 0.001), gender (β = 0.137, P = 0.008) and CRP (β = 0.144, P = 0.006) associated independently with QTc in RA patients. The crude hazard ratio (HR) for total mortality per 50-ms increase in QTc was 2.17 (95% CI 1.21, 3.90). This association remained significant [HR = 2.18 (95% CI 1.09, 4.35)] after adjustment for identified confounders (cardiovascular and RA specific), but was lost [HR = 1.73 (95% CI 0.83, 3.62)] when CRP was included in the model., Conclusion: A 50-ms increase in QTc interval associates with a doubling of the hazard for all-cause mortality in patients with RA. The observed contemporary association of QTc with CRP levels indicates a potentially hazardous interplay between inflammation and arrhythmogenesis. Future studies are needed to confirm the above findings and explore underlying mechanisms.

Objectives: RA associates with significantly increased morbidity and mortality from cardiovascular disease (CVD). This may be due to complex interactions between traditional CVD risk factors, systemic rheumatoid inflammation and the vasculature. We reviewed the current literature to answer: (i) whether there is sufficient evidence that patients with RA have altered vascular function and morphology compared with normal controls; (ii) whether there is sufficient evidence to determine if such changes relate predominantly to systemic inflammation; and (iii) whether any changes of vascular function and morphology in RA can be modified with therapy., Methods: The MEDLINE database was searched to identify publications from 1974 to 1 November 2010 pertaining to vascular function and morphology in RA. The total number of articles included in the present review was 93. This included 57 cross-sectional studies, 27 longitudinal studies without randomization and 9 longitudinal studies with randomization., Results: Vascular function and morphology was impaired in RA relative to healthy controls. The majority of studies reported no associations between systemic inflammation and vascular function. Treatment with anti-inflammatory medication resulted in both transient and long-term improvements in the vasculature, but only a few studies reported associations between change in inflammation and change in vascular function and morphology., Conclusion: The link between systemic inflammation and vascular function and morphology is not wholly supported by the available literature. Long-term studies examining specific predictors (including CVD risk factors) on the vasculature in RA are needed.

Obesity is a major threat for public health and its study has attracted significant attention in the general population, predominantly due to its association with significant metabolic and cardiovascular complications. In RA research, BMI is frequently reported as a demographical variable, but obesity, as such, has received little interest. This is surprising, in view of the clear associations of obesity with other arthritides, particularly OA, but also in view of the now-clear association of RA with increased cardiovascular morbidity and mortality. In this review, we summarize the studies that have looked into obesity in the RA population, evaluate their findings, identify knowledge gaps and propose directions for future research. We also pose a question of high clinical and research significance: is the use of BMI still a valid way of assessing obesity in RA?

Objectives: Part of the deleterious effects of systemic inflammation on the cardiovascular system of patients with RA may be exerted via increased propensity to hypertension. IL-6 and TGF-beta1 are important regulators of the inflammatory response. In some, but not all, studies, IL6 -174G/C (rs1800795) and TGFB1 869T/C (rs1982073) gene polymorphisms have been associated with hypertension in the general population. The present study addressed their potential association with hypertension in RA patients., Methods: TGFB1 869T/C and IL6 -174G/C were identified in 400 RA patients and 422 local, non-RA controls using real-time PCR and melting curve analysis. Binary logistic and linear regression models were used to identify the independence of the effects of the polymorphisms on hypertension., Results: Genotypic and allelic frequencies of the two polymorphisms were similar in RA and controls. Within the RA group, there was no significant association between IL6 -174G/C and hypertension, but TGF 869T-allele carriers had significantly increased prevalence of hypertension compared with CC homozygotes (70.2 vs 55.2%; P = 0.023). This association remained significant after adjustment for other hypertension risk factors and medication (odds ratio = 1.96; 95% CI 1.02, 3.77; P = 0.044), and was more pronounced in patients with increased systemic inflammation., Conclusions: This study suggests an association of TGFB1 869T/C, but not of IL6 -174G/C, with hypertension in RA patients. If this finding is confirmed in prospective studies, this polymorphism could be used as a screening tool for RA patients with higher risk of developing hypertension and lead to increased surveillance and earlier treatment.

RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.

Objectives: Resting energy expenditure (REE), one of the main components of total energy expenditure, can be measured via indirect calorimetry and/or predicted from equations. The latter may be misleading in RA, as they do not take into account the metabolic alterations occurring in RA. The objectives of this study are to evaluate the accuracy of widely used REE-predictive equations in RA patients against measured REE and to develop RA-specific equations., Methods: We assessed REE (via indirect calorimetry and several predictive equations), fat-free mass (FFM; via bioelectrical impedance) and disease activity (CRP) in RA patients and healthy controls. Data from 60 RA patients (experimental group) were used to assess the accuracy of existing REE equations and to develop new equations. The new equations were validated in an independent cross-validation group of 22 RA patients. These two groups were merged and two final equations were developed., Results: All equations significantly under-predicted measured REE (from 15% to 18.2%, all at P < 0.001) in the RA experimental group, but not in the control group. After both equations demonstrated a high validity in the cross-validation group, the new final REE prediction equations developed from the total RA sample (n = 82) were: Model 1: REE (kcal/day) = 126.1 x FFM(0.638) x CRP(0.045) (R(2) = 0.70) and Model 2: REE (kcal/day) = 598.8 x weight(0.47) x age(-0.29) x CRP(0.066) (R(2) = 0.62)., Conclusion: The new equations provide an accurate prediction of REE in RA patients and could be used for clinical monitoring of resting metabolism of these patients without the requirement for specialized personnel.

This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies are required to investigate the effects of exercise in improving the cardiovascular status of this patient population.

Objective: Rheumatoid arthritis (RA) associates with increased cardiovascular morbidity and mortality that is due to both traditional and novel cardiovascular risk factors. Hypertension (HT), one of the most common risk factors for cardiovascular disease, is highly prevalent in RA. The effects of long-term glucocorticoid (GC) therapy on blood pressure have not been established yet. This study examined whether GC exposure associates with HT in patients with RA., Methods: Four hundred consecutive RA patients with detailed clinical and laboratory assessments were categorized into three groups according to GC exposure: no or limited exposure (N/L-E); a low-dose (< 7.5 mg) long-term exposure (LD/LT-E); and medium-dose (> or = 7.5 mg) long-term exposure (MD/LT-E). The association of GC exposure with HT was evaluated using logistic regression analysis., Results: HT was more prevalent in the MD/LT-E group (84.7%) than the LD/LT-E or N/L-E groups (70.7 and 67.3%, respectively, P = 0.028). Logistic regression revealed increased odds for HT when comparing MD/LT-E with N/L-E, after adjustment for HT risk factors [odds ratio (OR) = 2.57, 95% CI 1.01-6.56, P = 0.049] and RA disease characteristics (OR = 3.64, 95% CI: 1.36-9.77, P = 0.01)., Conclusions: MD/LT GC exposure associates with a very high prevalence of HT. This appears to be independent of other risk factors for HT or of channelling bias due to disease severity, even though the latter cannot be excluded given the cross-sectional nature of our study. RA patients in this GC exposure group should be particularly targeted for early identification and aggressive management of HT.

Objectives: Rheumatoid arthritis (RA) is accompanied by increased resting energy expenditure (REE) and decreased fat-free mass (FFM). This is referred to as rheumatoid cachexia and is attributed to high levels of tumour necrosis factor-alpha (TNF-alpha). This study aimed to investigate the effects of anti-TNF-alpha therapy on REE, body composition, physical activity and protein intake in RA patients., Methods: Twenty RA patients [50% female; age: (mean +/- s.d.) 61.1 +/- 6.8 yrs; body mass index (BMI): 28.3 +/- 3.7 kg/m2] and 12 age-sex-BMI-matched healthy controls were assessed. REE (indirect calorimetry), body composition (bioelectrical impedance), the International Physical Activity Questionnaire (IPAQ), diet, Health Assessment Questionnaire (HAQ), disease activity [disease activity score 28 (DAS28), erythrocyte sedimentation rate (ESR), C-reactive protein] and serum TNF-alpha were measured before (Baseline) as well as 2 weeks (Time-1) and 12 weeks (Time-2) after initiation of anti-TNF-alpha treatment. Controls were only assessed at Baseline., Results: RA patients had significantly higher REE than controls at Baseline (1799.4 +/- 292.0 vs 1502.9 +/- 114.5 kcal/day, P = 0.002). Within the RA group, REE increased significantly between Time-1 and Time-2 (P = 0.001) but not between Baseline and Time-2. Sustained significant increases were observed in IPAQ (P = 0.001) and protein intake (P = 0.001). There were no significant changes in FFM or body fat. ESR (P = 0.002), DAS28 (P < 0.001), HAQ (P < 0.001) and TNF-alpha (P = 0.024) improved significantly. Physical activity (P = 0.001) and protein intake (P = 0.024) were significant between-subject factors for the elevation of REE., Conclusions: After 12 weeks of anti-TNF-alpha therapy, there were significant improvements in disease activity and physical function, as well as physical activity and protein intake, but no significant changes in REE or FFM. There is a need for longer-term studies in this field.

Objectives: Rheumatoid arthritis (RA) associates with excessive cardiovascular morbidity and mortality. Hypertension (HT) contributes significantly to the development of cardiovascular disease (CVD). Little is known about the factors that influence blood pressure (BP) in patients with RA. In this study, we assessed the prevalence of HT in a secondary care cohort of RA patients, and aimed to identify factors associated with its presence and inadequate control., Methods: A total of 400 consecutive RA patients were studied. HT was defined as systolic BP >/=140 mmHg and/or diastolic BP >/=90 mmHg or current use of antihypertensive drugs. The association of HT with several demographic and RA-related factors, comorbidities and drugs was evaluated using logistic regression., Results: HT was present in 282 (70.5%) patients. Of those, 171 (60.6%) received anti-hypertensive therapy, but 111 (39.4%) remained undiagnosed. Of those treated, only 37/171 (21.8%) were optimally controlled. Multivariable logistic regression revealed age (OR = 1.054, CI: 1.02 to 1.07, P = 0.001), body mass index [BMI (OR = 1.06, CI: 1.003-1.121, P = 0.038)] and prednisolone use (OR = 2.39, CI: 1.02-5.6, P = 0.045) to be independently associated with the presence of HT. BMI (OR = 1.11, CI: 1.02-1.21, P = 0.002) and the presence of CVD (OR = 4.01, CI: 1.27-12.69, P = 0.018) associated with uncontrolled HT., Conclusions: HT is highly prevalent in RA, under-diagnosed particularly in the young, and under-treated particularly in old RA patients with CVD. RA patients receiving steroids should be specifically targeted for screening and treatment; those with any cardiovascular comorbidity may require particularly aggressive monitoring and treatment strategies.

Context: Active smoking influences normal metabolic status and thyroid function., Objective: The objective was to assess experimentally the effects of 1 h of moderate passive smoking in a controlled simulated bar/restaurant environment on the metabolism and thyroid hormone levels in healthy nonsmokers., Participants: Eighteen (nine females, nine males) healthy individuals (mean +/- sd: age, 25.3 +/- 3.1 yr; height, 174.0 +/- 10.1 cm; weight, 65.2 +/- 13.7 kg) participated in the study., Design: In repeated-measures randomized blocks, participants visited the laboratory on 2 consecutive days. In the experimental condition, they were exposed to 1 h of moderate passive smoking at a carbon monoxide concentration of 23 +/- 1 ppm in an environmental chamber, whereas in the control condition participants remained in the same chamber for 1 h breathing normal atmospheric air., Main Outcome Measures: In both conditions, cotinine serum and urine levels, resting energy expenditure (REE), as well as concentration of T3, free T4, and TSH were assessed before participants entered the chamber and immediately after their exit. Heart rate and blood pressure were tested in 10-min intervals during all REE assessments., Results: The mean +/- sd difference of serum and urine cotinine levels (-0.27 +/- 3.94 vs. 14.01 +/- 6.54 and 0.05 +/- 2.07 vs. 7.23 +/- 3.75, respectively), REE (6.73 +/- 98.06 vs. 80.58 +/- 120.91) as well as T3 and free T4 (0.05 +/- 0.11 vs. 0.13 +/- 0.12 and 0.02 +/- 0.15 vs. 0.22 +/- 0.20) were increased in the experimental compared with the control condition at baseline and follow-up (P < 0.05). No statistically significant variation was observed in the mean difference of the remaining parameters (P > 0.05). Serum and urine cotinine values were linearly associated with REE (P < 0.05)., Conclusion: One hour of passive smoking at bar/restaurant levels is accompanied by significant increases in metabolism and thyroid hormone levels.