Medical Nutrition Therapy for Rheumatic DisordersDepartemen Ilmu GiziBLOK DERMATOMUSKULOSKELETAL

Osteoarthritis (OA)

Pathophysiology (OA) Most prevalence arthritisRisk factor:Obesity Female genderWhite ethnicityGreater bone densityRepetitive-use injury associated with athletics

OSTEOARTHRITISOBESITYAGINGCONGENITAL AND MECHANICALDERANGEMENT OF JOINTSLOAD IMPACT OR REPETITIVE USE INJURIESNUTRITION MANAGEMENT:Balanced diet with appropriate kcal for weightloss or maintenance of appropriate weightOmega-3 fatsAdequate calcium and vitamin DConsideration glucosamine and chondroitin Pathophysiology (modified) and nutrition management

Medical Nutrition TherapyExcess weight controlling obesity (disease prevention and improvement in symptom)Well balance dietReduced fat mass less inflammatory mediators from adipose tissue

Vitamin and mineralsReactive oxigen species need dietary antioxidantVitamin CVitamin EBeta caroteneSeleniumSupplement no benefit need further study

Improving dairy intake (calcium and vitamin D) at least Dietary Reference Intake (DRI)Comprehensive nutrition interviewing and counselingVitamin B6, vitamin D, and folate

Alternative therapiesSodium chondroitin sulfateGlucosamine hydrochlorideCapsaicinoids (chili peppers)S-adenosyl-L-methionine

Suggestion Chondroitin sulfate and glucosamine involved in cartilage production pain unknownThe National Institute of Health (NIH) undertook the Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT) 1500 mg of glucosamine (given as 500 mg, 3 x daily) with 1200 mg of chondroitin (given as 400 mg, 3 x daily) pain relief

No adverse effectBut, chondroitin can elicit a reaction in those with shellfish allergies

Capsaicin Fatty acid receptor that stimulates, then block, small diameter pain fibers by depleting them of the neurotransmitter substance P (P: the principal chemomediator of pain impulses from the periphery)Applied with glyceryl trinitrate to reduce on-site burning, can reduce pain

S-adenosyl-L-methionineReducing pain and improving mobility on people with OA Doses: 600 to 1200 mg/day

Rheumatoid Arthritis (RA)

RHEUMATOID ARTHRITISINFLAMMATIONAUTOIMMUNEDISORDERVIRAL OR BACTERIALINFECTIONHORMONALFACTORSGENETICSUSCEPTIBILITYNUTRITIONAL MANAGEMENT:Healthful balanced dietAvoidance of possible food allergensAdequate B vitaminsAdequate calcium and vitamin DOmega-3 fatty acidsFasting followed by vegetarian dietMediterranean diet

Medical Nutrition TherapyA comprehensive nutrition assessmentMedical history determine systematic impactPhysical examination sign and symptom nutrients deficienciesLikelihood of malnutrition indexCurrent weight and history of weight change over time (malnutrition excessive protein catabolism)

Diet History: Usual dietThe impact of handycapTypes of food consumedChanges in food tolerance secondary to oral, esophageal, and intestinal disordersImpact of disease on food shopping and preparation, self feeding ability, appetite, and intakeUse of elimination or other diets

Manifestations of RA articular and extraarticular limit the ability to perform nutrition-related ADLsArticular: Temporomandibular joint can impact the ability to chew and swallow and may necessitate changes in diet consistencyExtraarticular: increased metabolic rate secondary to the inflammatory process, Sjgrens syndrome, and changes in the gastrointestinal mucosa

Food allergen (modifying food composition)Reduction immunoreactivity to food antigensFasting following by vegetarian diet positive response A vegan, gluten-free diet improve symptom reduction of immunoreactivity to food antigens

Uncooked, lactobacilli-and-antioxidant rich, vegan diets positive outcomeLiving lactobacilli and chlorophyll-rich drinks and increased fiber intake positive effectsBut, afterall plant-based diet for reducing risk of CVD, hypertension, cancer, renal disease, and DMmore than just Rheumatic Disease

Energy Asses energy requirementActivity levels vary greatlyTotally sedentary: estimated at the resting energy expenditure and adjusted for weight changes that occur overtimeIntakes are poor, enteral or parenteral supplementation may be requiredHome nutrition support

Protein Well-nourished individual DRIs for age and sexProtein catabolism increased1.5 to 2 g/kg/day

Lipids Low-fats diets or fat-free diets counterproductive for patients susceptible to or afflicted by RAChange the type of fatOmega-3 fatty acids fish oilSome other oils of marine origin and a range of vegetable oil (olive and evening primrose oil)Flaxseed oil as effective as fish oil

Omega-3: abundant in fish such salmon, mackerel, herring, tuna, and some other fish oils-Lenolenic acid (ALA) has an 18-carbon chain with an omega-3 bond: abundance in flaxseed, walnut, and soy and canola (rapeseed) oils

Omega 6: found in safflower and other oilsIncreasing the amount of omega-3 fatty acids in the diet, production of mediators with antiinflammatory effects is increasedReducing arachidonat acids (animal food) minimized the inflammation in RA and enhance the benefits of fish oil supplementation

A diet that includes baked or boiled fish one to two times/week and/or an omega-3 supplement (approximate daily dose: EPA: 50 mg/kg/day, DHA: 30 mg/kg/day)But FDA has identified shark, swordfish, king mackerel, and tilefish as high-mercury fishAdditional benefits: fish oils and olive oils

Minerals,vitamins, and antioxidantsVitamin E (in addition to omega-3 and omega-6 fatty acids)affect cytokine and eicosanoid prod by decreasing proinflammatory cytokines and lipid mediatorsSelenium no beneficial effectsRoutine supplementation vitamin C, vitamin A, or Beta carotene not significant

Vitamin D lower risk, but need more studiesAdequate intakes folate, vitamin B6, and B12 because use MTX elevated homocysteine levels by low folate levelsPlasma Cooper levels increased, Ceruloplasmin rised (protective role)

Herbs and complementary therapyConcern of toxicity (FDA little regulation)Gamma-linolenic acid (GLA) oils of black currant, borage, evening primroseThunder god vine (Cina) long-term use suppress the immune system and/or reduce bone density

GLAAn omega-6 fatty acid that can be converted into the antiinflammatory PGE1 or into arachidonic acid, a precursor of the inflammatory PGE2

Thunder god vine (Tripterygium wilfordii)Inhibit mitogen-stimulated lymphoprolifieration and inhibitproduction of proinflammatory cytokines by monocytes, lymphocytes, and PGE2 production cia the COX-2 pathwayDoses: grater than 360 mg/day (clinical benefit)But, high doses and long-term usesuppress immun system

Gout

Occurs:After age of 35 yearsPredominantly affects men OLDER years equally distributed in both sexesOne comorbidity: OBESITYIncreased visceral adipose tissue aggrevate insulin resistance atherosclerosis disease risk

Although weight loss protective,but ketosis associated with fasting or a low CHO diet precipitate an attackHypertension and use of diuretics appear to be risk factors for gout as wellEpidemiologic studies an association between gout, dyslipidemia, diabetes mellitus, and insulin resistance syndrome

Medical Nutrition TherapyUric acids, derived from the metabolism of purines (parts of nucleoprotein)Low purine diet 2/3 from endogenous turn over1/3 from dietLow-fat dairy products, ascorbic acid, and wine consumption protective (alkaline ash effect)

Suggest: Consume meat, seafood, and alcoholic beverages moderateControl food portion sizeReduced noncomplex carbohydrat intake Goals: to achieve weight loss and improve insulin sensitivity

Meat and seafood increased serum uric acid levels but total protein intake was notModerate intake of purine-rich vegetables in not associated with an increased risk of goutAvoid metabolic stress (ketosis from excessive dieting)

Purin restricted (severe gout) 100-150 mg/dayIntakes of fluids (3 L/day) should encourage to assist with the excretion of uric acid and to minimize the possibility of renal calculi formation A calorie-restricted diet (1600 kcal):40% CHO (primarily complex)30% protein30% fat (primarily PUFA and MUFA)

Group 1: High purine content (100-1000 mg of purine nitrogen per 100 g of food)GooseHeartHerringKidneyMackerelMeat extractsMincemeatSardines Yeast (bakers and brewers) taken as supplementScallopsSweetbread

Should be omittes from the diet of patients who have gout (acute and remission stages)

Group 2: Moderate purine content (9-100mg of purine nitrogen per 100 g of food)FishPoltryMeatShellfish AsparagusBeans; driedLentilsMushroomsPeasSpinachOne serving of meat, fish, or fowl or 1 serving of vegetables from this group is allowed daily

Group 3: Negligible purine contentBread, white, and crackersButter or margarine (moderate because fat content)Cake, cookiesCarbonated beveragesChocolateCoffeeEggsVegetables (except those in group 2)

FruitHerbsIce creamMilkMacaroni productNoodlesNutsOil SaktRiceSugar and sweetTea

Foods may use daily

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