Medical Nutrition Therapy

for Rheumatic Disorders

Departemen Ilmu Gizi
BLOK DERMATOMUSKULOSKELETAL

Osteoarthritis (OA)

Pathophysiology (OA)
Most prevalence arthritis
Risk factor:

Obesity

Greater bone density

Female gender

White ethnicity

Repetitive-use injury associated with athletics

Pathophysiology (modified) and nutrition management

OBESITY

AGING
OSTEOARTHRITIS

LOAD IMPACT OR REPETITIVE

USE INJURIES

CONGENITAL AND MECHANICAL

DERANGEMENT OF JOINTS

NUTRITION MANAGEMENT:
Balanced diet with appropriate kcal for weightloss or
maintenance of appropriate weight
Omega-3 fats
Adequate calcium and vitamin D
Consideration glucosamine and chondroitin

Medical Nutrition Therapy

Excess weight controlling obesity
(disease prevention and improvement in
symptom)
Well balance diet
Reduced fat mass less inflammatory
mediators from adipose tissue

Vitamin and minerals

Reactive oxigen species need dietary

antioxidant
Vitamin C
Vitamin E
Beta carotene
Selenium

Supplement no benefit need further

study

Improving dairy intake (calcium and

vitamin D) at least Dietary Reference
Intake (DRI)
Comprehensive nutrition interviewing and
counseling
Vitamin B6, vitamin D, and folate

Alternative therapies
Sodium chondroitin sulfate
Glucosamine hydrochloride
Capsaicinoids (chili peppers)
S-adenosyl-L-methionine

Suggestion
Chondroitin sulfate and glucosamine
involved in cartilage production pain
unknown
The 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 effect
But, 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-methionine
Reducing pain and improving mobility on
people with OA
Doses: 600 to 1200 mg/day

Rheumatoid Arthritis (RA)

INFLAMMATION
AUTOIMMUNE
DISORDER

RHEUMATOID
ARTHRITIS

HORMONAL
FACTORS

NUTRITIONAL MANAGEMENT:
Healthful balanced diet
Avoidance of possible food allergens
Adequate B vitamins
Adequate calcium and vitamin D
Omega-3 fatty acids
Fasting followed by vegetarian diet
Mediterranean diet

GENETIC
SUSCEPTIBILITY

VIRAL OR BACTERIAL
INFECTION

Medical Nutrition Therapy

A comprehensive nutrition assessment

Medical history determine systematic
impact
Physical examination sign and symptom
nutrients deficiencies
Likelihood of malnutrition index
Current weight and history of weight change
over time (malnutrition excessive protein
catabolism)

Diet History:
Usual

diet
The impact of handycap
Types of food consumed
Changes in food tolerance secondary to oral,
esophageal, and intestinal disorders
Impact of disease on food shopping and
preparation, self feeding ability, appetite, and
intake
Use of elimination or other diets

Manifestations of RA articular and

extraarticular limit the ability to perform
nutrition-related ADLs
Articular:

Temporomandibular joint can impact the

ability to chew and swallow and may necessitate
changes in diet consistency
Extraarticular: 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 antigens
Fasting 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 outcome
Living lactobacilli and chlorophyll-rich
drinks and increased fiber intake
positive effects

But, afterall plant-based diet for

reducing risk of CVD, hypertension,
cancer, renal disease, and DMmore
than just Rheumatic Disease

Energy
Asses energy requirement
Activity levels vary greatly
Totally sedentary: estimated at the resting
energy expenditure and adjusted for weight
changes that occur overtime
Intakes are poor, enteral or parenteral
supplementation may be required
Home nutrition support

Protein
Well-nourished individual DRIs for age
and sex
Protein catabolism increased
1.5 to 2 g/kg/day

Lipids
Low-fats diets or fat-free diets
counterproductive for patients susceptible
to or afflicted by RA
Change the type of fat
Omega-3 fatty acids fish oil
Some 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

oils
Increasing the amount of omega-3 fatty
acids in the diet, production of mediators
with antiinflammatory effects is increased
Reducing 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
fish
Additional benefits: fish oils and olive oils

Minerals,vitamins, and antioxidants

Vitamin E (in addition to omega-3 and
omega-6 fatty acids)affect cytokine and
eicosanoid prod by decreasing
proinflammatory cytokines and lipid
mediators
Selenium no beneficial effects
Routine supplementation vitamin C,
vitamin A, or Beta carotene not
significant

Vitamin D lower risk, but need more

studies
Adequate intakes folate, vitamin B6, and
B12 because use MTX elevated
homocysteine levels by low folate levels
Plasma Cooper levels increased,
Ceruloplasmin rised (protective role)

Herbs and complementary therapy

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

GLA
An 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 pathway
Doses: grater than 360 mg/day (clinical
benefit)
But, high doses and long-term
usesuppress immun system

Gout

Occurs:
After age of 35 years
Predominantly affects men OLDER years
equally distributed in both sexes

One comorbidity: OBESITY

Increased 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 attack
Hypertension and use of diuretics appear
to be risk factors for gout as well
Epidemiologic studies an association
between gout, dyslipidemia, diabetes
mellitus, and insulin resistance syndrome

Medical Nutrition Therapy

Uric acids, derived from the metabolism of
purines (parts of nucleoprotein)
Low purine diet
2/3 from endogenous turn over
1/3 from diet
Low-fat dairy products, ascorbic acid, and
wine consumption protective (alkaline
ash effect)

Suggest:
Consume meat, seafood, and alcoholic
beverages moderate
Control food portion size
Reduced 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
not
Moderate intake of purine-rich vegetables
in not associated with an increased risk of
gout
Avoid metabolic stress (ketosis from
excessive dieting)

Purin restricted (severe gout) 100-150

mg/day
Intakes 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% protein
30% fat (primarily PUFA and MUFA)

Group 1: High purine content (100-1000 mg

of purine nitrogen per 100 g of food)

Goose
Heart
Herring
Kidney
Mackerel
Meat extracts
Mincemeat
Sardines

Yeast (bakers and

brewers) taken as
supplement
Scallops
Sweetbread

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)

Fish
Poltry
Meat
Shellfish

Asparagus
Beans; dried
Lentils
Mushrooms
Peas
Spinach
One serving of meat, fish, or
fowl or 1 serving of
vegetables from this
group is allowed daily

Group 3: Negligible purine content

Bread, white, and crackers

Butter or margarine (moderate
because fat content)
Cake, cookies
Carbonated beverages
Chocolate
Coffee
Eggs
Vegetables (except those in
group 2)

Fruit
Herbs
Ice cream
Milk
Macaroni product
Noodles
Nuts
Oil
Sakt
Rice
Sugar and sweet
Tea

Foods may use daily

Thank You