Rheumatoid Arthritis is on the rise. The big question: Why?

From healthcentral.com

Cases of RA are predicted to nearly double in the next 30 years. Our experts explain why, and whether it’s a trend that can be reversed 

Despite everything you’ve read about innovations in medicine eradicating diseases from hepatitis B to smallpox, when it comes to rheumatoid arthritis (RA), the trend is disturbingly the opposite. According to the most recent findings from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), “the single largest and most detailed scientific effort ever conducted to quantify levels and trends in health,” RA cases are expected to rise a shocking 80% over the next 30 years.

Current estimates put the number of people with rheumatoid arthritis globally around 18 million; by 2050, the GBD estimates that number will increase to 31.7 million. It’s a massive increase for a condition that has been celebrated by the medical community in recent years for its treatment success rates with the introduction of specialized medications called biologics and Janus kinase inhibitors. (Indeed, deaths from RA are in decline largely due to therapeutic innovations, according to a review looking into the GBD study findings that was published last year in Lancet Rheumatology.)

Given how far we’ve come to treat it, it’s a surprise and concern to experts that this autoimmune disease, which targets not only your joints but heart, lungs, and nervous system as well, is still growing in communities around the world. What makes experts so certain a spike in rheumatoid arthritis is coming? What’s possibly driving it? And what risk factors are in your control to reduce your chances of developing it? We went to the experts for the answers to these questions and more.

Where We Stand Now With RA

To put the current predictions about RA into perspective, it’s important to note what trends clinicians have been seeing in both the number of cases and disease burden for some time.

In the United States, it’s estimated that 1.3 million American adults have RA. Those statistics are debated among experts, who note that they are derived from studies on RA that are “inconsistent” in their findings, according to a recent article in the Journal of Clinical Medicine. (Some studies show an increase in RA prevalence, others show a decrease, and still others show no measurable change at all.)

To complicate matters, another recent study in Frontiers of Medicine points out that because the classifications for an early RA diagnosis were updated in 2010, an increase in incidence for RA may be due primarily to increased diagnoses under the new criteria, rather than an increase in actual disease cases.

Why Scientists Are Concerned

The GBD study itself is a research undertaking looking at the health impact of not just RA, but also “hundreds of diseases, injuries, and risk factors;” it involved some 9,000 researchers in more than 160 countries and territories worldwide overall over multiple years, according to the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, which leads the study.

For RA, the prevalence—which includes the number of cases of a disease, according to the Centers for Disease Control and Prevention (CDC)—was estimated in 204 countries and territories from 1990 to 2020 by researchers called the GBD 2021 Rheumatoid Arthritis Collaborators. The researchers used population-based studies and medical claims data from dozens of studies to reach their conclusions that RA cases would mushroom, as would the time of disability (or burden) of the disease.

“Multiple factors can be contributing toward the increased incidence and burden of RA,” says Vicky Nahra, M.D., a rheumatologist and assistant professor in the division of rheumatology at Case Western Reserve University in Cleveland, OH. From lifespan to lifestyle, experts have their eye on a few key variables.

Aging Population

One reason behind the rise in global RA prevalence is the sheer number of people who are aging into the demographic that traditionally has the highest rates of the disease. “We know RA occurs more in women and in older individuals, and given our aging population, it is expected to see more cases,” says Dr. Nahra.

In the next 30 years, the U.S. population is projected to grow by about 0.3% per year overall, according to the Congressional Budget Office. Meanwhile, experts expect an increase of 111% in the population 65 and older by 2050, the Pew Research Center reports. While you can develop RA at any age, it most often starts affecting people in their 30s to 60s, according to the Johns Hopkins Arthritis Center, and researchers have found that RA is a common inflammatory disease in older age groups.

Climbing Obesity Rates

Research suggests there’s an increased risk of developing RA if you have obesity, per a recent review of studies on the topic. According to that review, higher body mass index (BMI) in middle age and early adulthood, and larger waist circumference were all associated with an increased risk of developing RA. Being obese can also make RA symptoms worse, according to the Arthritis Foundation, and even impact RA meds’ effectiveness, which both can contribute to the overall burden of the disease.

Obesity (defined as BMI of 30 or greater) prevalence doubled in the U.S. from the late 1970s to 2000, and CDC statistics show it has continued to climb, from 30.5% of Americans considered obese in 2000 to 42.5% in 2022, the most recent data available.

But whether obesity will continue to be a predominant driver of rheumatoid arthritis for the next three decades remains to be seen, notes Grace C. Wright, M.D., Ph.D., a consultant rheumatologist in New York City and the founder and president of the Association of Women in Rheumatology (AWIR). For instance, the recent advent of new anti-obesity drugs might help in slowing RA rates that are tied to obesity, Dr. Wright points out, as well as “shifting patient outcomes for those who already have rheumatoid arthritis,” she says.

Smoking

In the GBD study, the only risk factor analysed in relation to RA prevalence was smoking. With regard to RA, smoking is specifically associated with a certain type of this condition: Research has found an association between smoking and an increased risk of developing seropositive RA, according to a recent journal article. When you have seropositive RA, blood tests typically show high levels of anti-cyclic citrullinated peptides (anti-CCPs), a type of antibody, the Arthritis Foundation reports. It was once thought that the other type—seronegative RA, when you don’t have high levels in certain blood tests—was a milder form of the condition, but doctors are realizing it can be just as damaging to joints as seropositive RA, per Dr. Wright. So it’s key to be diagnosed with either type of the condition ASAP to reduce that damage, and to understand the seropositive connection if you’re a smoker.

But herein lies an important nuance: This smoking issue may be less impactful to U.S. numbers of RA cases than in other countries. For instance, some places have a higher prevalence of smoking than the U.S., such as the World Health Organization’s (WHO) defined South-East Asian Region. While smoking is increasing in some countries, like Congo, Egypt, and Indonesia, the WHO reports, smoking is on the decline in the U.S.

Air Pollution

Frequent exposure to air pollution is also associated with higher risk of developing autoimmune diseases, including RA, research has found. In the U.S., air pollution continues to be an issue, even after significant improvements in air quality since the Clean Air Act was established in 1970, according to the U.S. Environmental Protection Agency (EPA).

A 2023 “State of the Air” report from the American Lung Association (ALA) found that almost 36% of Americans, or 119.6 million people, live in areas in the U.S. that have failing grades from unhealthy levels of ozone or particle pollution. And the report found that 63.7 million Americans live in counties that have failing grades for daily spikes in “deadly particle pollution,” which was “the most ever reported under the current national standard.” Health issues from air pollution are becoming especially apparent as we see air quality diminish worldwide with climate change, Dr. Wright points out. It’s causing things like massive wildfires that darken our skies and fill the air with pollutants.

Other Potential Factors

Another important reason for the predicted jump in RA prevalence and burden? Doctors now have better tools for diagnosis, Dr. Nahra says. In the past, they often had to rely on X-rays—which can show RA activity as calm, even during active progression, according to the Arthritis Foundation—but newer technology, like musculoskeletal ultrasound (MSUS) and magnetic resonance imaging (MRI), can show inflammation and bone erosion that X-rays can’t.

Some patients also now have better access to medical care, specifically rheumatology, for proper diagnoses, she says, with telehealth expansion during the pandemic helping to expand access. That means they’re getting diagnosed at a potentially higher rate than before. And this might only accelerate in the future to account for the projections bringing larger increases than the historically upward trending curve.

COVID-19 itself may even play a role in the increasing number of cases, thinks James Schiff Topilow, M.D., a rheumatologist at Hackensack University Medical Center in Hackensack, NJ. “Multiple epidemiologic studies have linked COVID infections with increased rates of vasculitis and various other autoimmune diseases, including RA,” Dr. Topilow says. “Given COVID is not going away anytime soon, and our country’s own median age is projected to increase, our country will not be immune to these processes.”

How to Reduce Risk Factors

The big question: Is anything we can do now to reduce RA risk factors, in a bid to lower future prevalence rates? That depends, Dr. Wright says. Some risk factors for the condition are modifiable and others, like the genetic connection to RA, are not. In fact, one study found that having a first-degree relative with RA can make you more than twice as likely to develop the condition than someone who doesn’t.

Still, if you’re looking for a way to proactively contribute to a future RA decline, these are three modifiable RA risk factors to consider. While they may or may not have an impact on global rheumatoid arthritis rates, they’ll at the very least have a positive impact on your overall health.

Air Pollutants

According to the ALA, no matter where you live, you can take steps to protect yourself from air pollutants. Step one, check your daily air pollution forecast for where you live (www.AirNow.gov is one potential resource): The ALA advises not exercising outside when pollution is estimated to be high and instead take your exercise indoors, like a gym or a walk through the local mall, to reduce your exposure to breathing in harmful air pollutants. The EPA also recommends investing in a portable air cleaner for your home or office to help reduce pollutants indoors. The agency reports that the most effective way to make indoor air healthier is to reduce or clean out pollutants.

Obesity

Losing weight and maintaining a healthy BMI might help reduce this RA risk factor, Dr. Nahra explains. You can do so through small steps, Dr. Wright says. “We have many things that we can do with weight management that don’t necessarily have to be that you’re taking a pill, but they’re healthy behaviours—like, eat a little bit more green, and a little bit less brown,” she says. “Change the colour coding of your food. Find ways to make it fun.”

A diet high in fiber and prebiotics, including vegetables, fruit, beans, legumes, unsweetened yogurt, nuts and seeds can help maintain a healthy microbiome and weight that can assist with RA management, says Leslie Axelrod, N.D., a staff physician at Sonoran University in Tempe, AZ, specializing in integrative rheumatology.

Smoking

Doing a smoking cessation program ASAP is advisable if you have RA or are at risk for it, our experts say. There are many helpful resources to support you in your journey to stop smoking—like the ALA’s Freedom From Smoking program; a website with tools, tips, and info on stopping smoking started by the National Cancer Institute called Smokefree.gov; and an overview on all things quitting smoking from the American Heart Association. Because it’s worth it—one study of women in the Nurses’ Health Studies found that seropositive RA risk was reduced by 37% in the women studied who didn’t smoke for 30 years or more when compared to those who had just stopped smoking.

Reducing the Burden of RA

Back to the GBD study—which showed that there was not only a rise in RA cases, but also an increased burden of living with the condition. The latter, say experts, should be considered a modifiable variable—as long as you remain vigilant about managing your care.

“We can prevent damage accumulation if we quickly set out and control disease activity,” Dr. Topilow says. He thinks society has normalized joint pain, to the detriment of people with RA. A delay in care can lead to disease progression, Dr. Topilow says, allowing for greater disease burden which can include disability from joint damage and loss of healthy years of life, as the GBD study shows.

“People should be certain to let their doctors know if they have new onset of joint pain,” he says. “Especially pain that is associated with morning stiffness over 30 to 60 minutes and pain that improves with activities, which are more typically seen in inflammatory, autoimmune processes such as RA, and should not just assume the pain is a normal part of the aging process.”

The earlier RA is diagnosed, the better for easing the burden of the disease, Dr. Nahra agrees. “It is critical for RA to be diagnosed as soon as possible so that we can initiate treatment and prevent damage to the joints and subsequent loss of function or deformities,” she explains.

It’s not just the joints and related disability to consider—RA can have implications throughout the body, Dr. Axelrod says. “It also has other effects, including cardiovascular risks and changes to the lungs,” she explains. Left untreated, it can cause further damage to the joints, surrounding tissue, and heart, nervous system, and lung issues, the WHO reports.

The Future of Rheumatoid Arthritis

It would be ideal, agree researchers and clinicians, to not only be able to predict trends in RA prevalence, but to know for certain what’s driving them, so as to head any spike in disease off at the proverbial pass. But while experts have theories and likely contributors, there is no single smoking gun when it comes to the anticipated rise in rates over the next three decades.

Instead, while rheumatoid arthritis prevalence and burden continue to increase around the world, including in the U.S., the take-home message for most of us is: Do what you can to reduce your changeable risk factors. And if you are experiencing the early warning signs of RA such as stiffness, swelling, tenderness, or pain in your joints, seeing your doctor to get a diagnosis is key. The disease—if left untreated—can be a more debilitating and challenging condition than it need be. “There is no need to suffer in silence,” Dr. Topilow says. “There are new treatments for RA that can help lessen symptoms and minimize joint damage.”

https://www.healthcentral.com/condition/rheumatoid-arthritis/why-rheumatoid-arthritis-is-on-the-rise