Association between rheumatoid arthritis with gender, age, obesity and smoking among middle aged and old aged population-A Survey

Kaviyaselvi Gurumurthy1, Karthik Ganesh Mohanraj*1, Don K. R.2 1Department of Anatomy, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600 077, Tamil Nadu, India 2Department of Oral and Maxillofacial Pathology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600 077, Tamil Nadu, India


INTRODUCTION
Across the globe, the number of deaths due to tobacco and nicotine consumption rises to one-ifth of the general population. (Johnson, 2020) The most common form of tobacco consumption is practised by smoking. (Sekar, 2019) Smoking refers to the inhalation of tobacco vapours from pipes or cigars either through the oral cavity or through direct inhalation of the vapours. (Seppan et al., 2018) The use of tobacco most commonly leads to diseases such as heart and lung cancer, strokes, heart attacks, pulmonary diseases and emphysema apart from other hereditary diseases (Krishna and Babu, 2016). Apart from smoking one of the signi icant factors that affect the mental and physical health of an individual date back to the concept of obesity. (Nandhini et al., 2018) Obesity is a common yet preventable disease which is non-communicable. (Subashri and Thenmozhi, 2016) It occurs due to the abnormal or excess deposition and accumulation of fat in the adipose tissues leading to a puffed-up appearance. (Thejeswar and Thenmozhi, 2015) The fat generally accumulates in the peripheral parts of the body, and this accumulation relates to the risk of various diseases such as type-2 diabetes, COPD and other deadly conditions (Ofei, 2005) . Rheumatoid arthritis or commonly called RA is a common chronic in lammatory disease that causes in lammation of joints on both sides of the body leading to a decrease in the immune response of the body. (Sriram et al., 2015) A person with in lammatory joints passes several stages before reaching its peak. (Keerthana and Thenmozhi, 2016) The irst phase represents the start or onset of rheumatoid arthritis. The second phase usually determines if rheumatoid arthritis shall persist or perish. The third and fourth stages typically determine the type of RA that the person shall develop based on the lifestyle features and symptoms. (Heidari, 2011) The association between the occurrence of rheumatoid arthritis and age varies with the extent of smoking. Smokers are prone to develop rheumatoid arthritis after 20 years of smoking, or in other words, smokers with greater than or equal to 25 packets of cigarettes a month are more susceptible to rheumatoid arthritis. (Saag et al., 1997) The exposure to various environmental factors increases the risk of rheumatoid arthritis in smokers predominantly in East Indian areas depending on four signi icant elements, namely joint involvement, serology, duration of the symptom and acute phase reactants. (Pratha and Thenmozhi, 2016) This criterion applies to any patient who shows even one of the above symptoms. (Menon and Thenmozhi, 2016) This new identi ication modality helps in early diagnosis and treatment of rheumatoid arthritis, thereby preventing and minimising the loss of deaths due to the same. (Okada, 2014) In association with obesity, 18% of RA patients were recorded as obese. (Samuel and Thenmozhi, 2015) The basal metabolic rate does not signify an accurate measure, but metabolic alterations help in the reduction of fat-free measures without bringing about any change in body weight. (Stavropoulos-Kalinoglou et al., 2011) On comparing age with the occurrence of rheumatoid arthritis, people falling in the category of 30-50 years of age suffer from an increased risk of occurrence of RA. previous researches suggested that people aged 18-44 years were less susceptible to this disease with a total of 7.1% of the population affected. (Patel and Bhadoriya, 2011) Despite the advancing technologies, the awareness and spread of rheumatoid arthritis remain limited only to educated individuals, and the number of deaths due to this disease should be brought under control. The name of this research is to analyse              the relationship between age, gender, obesity and smoking with rheumatoid arthritis and to determine the need to spread awareness about the same among the middle and old aged population.

MATERIALS AND METHODS
The present study has been conducted through an online setting among the middle and old aged population in Chennai city. The institutional review board had obtained the research approval, and no human and ethical approval was necessary. The present study involved two principal individuals, namely the primary investigator and the guide.
The present study involved a sample size of 100 participants and the questionnaire prepared was circulated through an online Google forms link and the sampling method that was suggested was a simple random sampling. For the present study, the measures taken to minimise the bias was randomisation which included all the variables. The internal validity of the study included the pretesting of the questionnaire. In contrast, the external validity included the homogenisation and replication of experiment along with the cross veri ication with already existing studies.
The statistical test performed was the student's unpaired 'T' test, and the statistical software used what's the SPSS version 22.0. In the present study, the independent variables included are education, food habits and occupation, whereas the dependent variables included are age, gender, duration of smoking and obesity of the individuals. Chi-square test was used for statistical analysis for the association.

RESULTS AND DISCUSSION
In the survey study, the age of the participants was grouped into young adult, middle-aged and old age. The ages ranging from 25-35 were 19.80%, 35-45 were 56.44%, and above 45 were about 23.76% (Figure 1). Age grouped from 25-35 were 19.80% (blue colour), 35-45 were 56.44% (red colour) and above 45 were about 23.76% (green colour).
In the present study, the percentage of females who attended the questionnaire was 51.5%, and the rate of males included was 48.5% (Figure 2), which females were 51.49% (blue colour) and males were 48.51% (red colour).
The survey participants responded that the causes for RA were due to many factors. 17.82% of the population responded that RA occurs due to defects in blood supply to skeletal components, 30.69% said that it was due to weakening of bones and tissues and 51.49% responded it was due to in lammation of joints (Figure 4). where 17.82% (blue colour) -Defect in blood supply to skeletal components, 30.69% (red colour) -Weakening of bones and tissues and 51.49% (green colour) -In lammation of joints The percentage of people opting for the type of disease that rheumatoid arthritis is. 6.9% felt that rheumatoid arthritis is an infectious disease; 43.6% voted for auto-immune disease and 49.6% for systemic disease ( Figure 5). where 6.39% (blue colour)-infectious disease, 43.56% (red colour)systemic disease and 49.56% (green colour)-autoimmune disease.
14.9% felt that children are most affected by RA, 39.6% voted for men, while 45.5% opted for women ( Figure 6). where 14.85% (blue colour)-children, 39.60% (red colour)-women and 45.54% (green colour)-men Similar results were provided by Patel, P. K. and Bhadoriya, U. 2011 with 52.8%. Figure 7 represents that 23.8% were aware of the relation of rheumatoid arthritis and nicotine, while 76.2% were unaware. Similar results were provided by (Kvien, 2006), with 95% awareness rate. where 23.76% (blue colour)-No and 76.24% (red colour)-Yes Figure 8 represents the people having RA and has the habit of smoking. Subjects having RA with the number of years of smoking were 34.7% for 10 to 15 years of smoking, 46.5% for 16 to 20 years and 18.8% for greater than 20 years. Similar results were provided by (Protogerou, 2013) with 56.2%. where 18.81% (blue colour)->2 years, 34.65% (red colour)-16-20 years and 46.53% (green colour)-10-15 years. Figure 9 shows that 8.9% felt that obesity does not affect rheumatoid arthritis. 46.5% but obesity increases the risk of rheumatoid arthritis and 44.6% but decreases the risk. where 8.91% (blue colour)does not affect, 44.55% (red colour)-decreases the risk and 46.53% (green colour)-increases the risk Similar results were provided by (Protogerou, 2013) with 29.06% (Protogerou, 2013;Hafeez and Thenmozhi, 2016). Figure 10 represents 40.6% shows an increase in in lammatory cytokines as a trigger factor in obesity for rheumatoid arthritis, 44.6% increase in adipose tissues and 14.9% for both. where 14.85% (blue colour)-both, 40.59% (red colour)-Increase in in lammatory cytokines and44.55% (green colour)-Increase in adipose tissue.
Similar results were provided by (Neame and Hammond, 2005) with 22.5% increase in in lammatory cytokines.
Twenty-ive participants aged 35-45 and 32 participants of the same age group were aware that rheumatoid arthritis was due to in lammation of joints, and it is an auto-immune disorder, respec-tively. It was found that there was an association between age and awareness on RA, where Chisquare test showed p=0.047 indicating statistically signi icant (p<0.05) (Figure 16). X-axis represents age and y-axis represents the number of participants responded.
Also, it was found that there was no association between age and type of disorders of RA, where Chisquare test showed p=0.211 indicating statistically not signi icant (p>0.05) (Figure 17). X-axis represents age and y-axis represents the number of participants responded.
From the present study, it was observed that there was no association between age and susceptibility to RA, where Chi-square test showed p=0.439 indicating statistically not signi icant (p>0.05) (Figure 18) (Kvien, 2006). X-axis represents age and y-axis represents the number of participants responded.
Also, it was found from this survey study that there was an association between age and nicotine exposure, Chi-square test showed p=0.032 indicating statistically signi icant (p<0.05) (Figure 19). X-axis represents age and y-axis represents the number of participants responded.
Thirty-eight participants of the age group 35-45 were aware of the effects of nicotine and the occurrence of RA in smokers (Heidari, 2011). Thus, this showed that there was an association between age and development of RA in smokers, where Chisquare test showed p=0.955 indicating statistically signi icant (p<0.05) (Figure 20). X-axis represents age and y-axis represents the number of participants responded.
From the survey analysis, it was observed that there was no association between age and relation of obesity with RA, where Chi-square test showed p=0.304 indicating statistically not signi icant (p>0.05) (Figure 21). X-axis represents age and y-axis represents the number of participants responded.
It was found that there was no association between age and factor in obesity that causes RA, where Chisquare test showed p=0.829 indicating statistically not signi icant (p>0.05) (Figure 22). X-axis represents age and y-axis represents the number of participants responded.
From the data, it was found that there exists an association between age and relevance of sex hormones to RA, where Chi-square test showed p=0.029 indicating statistically signi icant (p<0.05) (Figure 23). X-axis represents age and y-axis represents the number of participants responded.
The data showed that there was no association between age and effect of oestrogen on RA; Chisquare test showed p=0.412 indicating statistically not signi icant (p>0.05) (Figure 24). X-axis represents age and y-axis represents the number of participants responded.
It was found that there was no association between age, exercise and RA, where Chi-square test showed p=0.273 indicating statistically not signi icant (p>0.05) (Figure 25). X-axis represents age and y-axis represents the number of participants responded.
From the present survey study, it was found that there was no association between age and treatment of RA, where Chi-square test showed p=0.739 indicating statistically not signi icant (p>0.05) (Figure 26). X-axis represents age and y-axis represents the number of participants responded.
Also, it was found that there was no association between age and awareness among participants on RA. Chi-square test showed p=0.107 indicating statistically insigni icant (p>0.05) ( Figure 27). X-axis represents age and y-axis represents the number of participants responded.
Thus, it is inferred from the survey analysis that there was not much awareness on the effects of RA and its long term consequences among the people and this necessitates for spreading the consciousness, a piece of general and medical knowledge on RA among all age groups. The data obtained from the present study prove to be similar to the previous research studies conducted on similar ields of RA, and the percentage obtained for each question matches the percentage obtained by previous studies. Thus, the survey serves as evidence and adds to the consensus that there is an association between gender, age, obesity and smoking with rheumatoid arthritis and can be utilised for further clinical studies. Limitations of the study included small sample size, homogenous population and restriction to a geographically local region.

CONCLUSION
Rheumatoid arthritis can be prevented by a healthy, balanced diet, regular exercise and a change in lifestyle and habitat. Spread of awareness concerning RA and its effective treatment modalities among the middle-aged and elderly population can decrease the risk of RA and therefore enhance the quality of life. Thus, within the limitations of this study, we conclude that there was an association between rheumatoid arthritis with gender, age, obesity and smoking condition among the middle-aged and old aged population. But the awareness about the effects of RA and its long term consequences among the people remains sparse and need to be improved by educational and several regulatory interventional strategies among the people of all ages.