Nutrition Intervention: Rheumatoid Arthritis

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Nutrition Intervention Rheumatoid Arthritis
Katelyn Dold
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Objectives

• Understand the development of Rheumatoid
  Arthritis
• Be able to identify different diagnosis for
  Rheumatoid Arthritis
• Introduction to common RA medications
• Describe the nutritional intervention on patients
  with Rheumatoid Arthritis
• Understand current research in Rheumatoid
  Arthritis
• Be able to identify ethical issues in treatment

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Types of Arthritis

• More than 100 different types
• Carpal Tunnel
• Lymes Disease
• Two major types
• Osteoarthritis
• Rheumatoid Arthritis

Arthritis Foundation (2011)
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How does RA differ fromother types of Arthritis?

• Rheumatoid Arthritis affects the joints on both
  sides of the body. RA causes joint pain,
  stiffness, and fatigue.
• Osteoarthritis is caused by a loss of cartilage
  in a joint. Osteoarthritis is often caused by
  wear and tear damage on a joint.

Nelms, et al. (2010)
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What is Rheumatoid Arthritis?

• An autoimmune disease
• Leads to inflammation of the joints and
  surrounding tissues
• http//www.webmd.com/rheumatoid-arthritis/ra-tv?ca
  tId10vidId091e9c5e802e881e

• An autoimmune disease
• Leads to inflammation of the joints and
  surrounding tissues

• An autoimmune disease
• Leads to inflammation of the joints and
  surrounding tissue

• An autoimmune disease
• Leads to inflammation of the joints and
  surrounding tissues

• An autoimmune disease
• Leads to inflammation of the joints and
  surrounding tissues

Nelms, et al. (2010)
Nelms, et al. (2010)
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Where it Can Occur Demographically?

• Estimated 1.3 million people in the United States
• 1 of the adult population diagnosed
• More common in women than men
• Common in adults 30-60 years old

Arthritis Foundation (2011)
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Where it Can Occur Physically?

• Can occur in any joint of the body
• Very common in hand and knee joints
• Often occurs on both sides of the body equally

• Nelms, et al. (2010)

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What Causes Rheumatoid Arthritis?

• Main cause unknown
• The bodys immune system mistakenly confuses the
  surrounding healthy tissue as foreign and attacks
  on the healthy joints
• May be linked to sex, age, family, smoking

Nelms, et al. (2010)
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How Rheumatoid Arthritis differs from a normal
joint?

• Inflammation characterized by swelling,
  stiffness, warmth, and severe pain in the joint
• As the stages progress, the pannus can fill the
  synovial cavity and invade the joint

Escott-Stump, S. (2008)
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What are Risk Factors?

• Most common in women than men
• 31
• Between the ages of 30 and 60
• Can occur in older teensJuvenile Arthritis
• Family History
• Increased risk
• Smoking
• Increased risk

Saevarsdottir (2011)
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Signs Symptoms

• Joint Pain
• Joint Swelling
• Rheumatoid Nodules
• Fatigue
• Morning Stiffness
• Fever
• Weight loss
• Flare-Ups

Nelms, et al. (2010)
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How Rheumatoid Arthritisis Diagnosed?

• Symptoms must be present for at least six weeks
• Clinical indicators must be preformed and tested
  positive through blood tests
• Symptoms come and go sporadically making it
  difficult to diagnose Rheumatoid Arthritis

Escott-Stump, S. (2008)
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2010 RA Classication Criteria

• Score-based test for RA based on 4 areas
• Joint involvement
• Serology test results
• Acute phase reactant test results
• Patient self-reporting of signs and symptoms
• A score of 6 of 10 or greater must be met for a
  classification of definitive RA.

Wheeless. (2011)
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Joint Involvement

• Joint involvement consists of swelling or
  tenderness upon examination. Points are counted
  as follows
• 1 large joint (shoulders, elbows, hips, knees,
  ankles) 0 points
• 2-10 large joints 1 point
• 1-3 small joints 2 points
• 4-10 small joints 3 points
• More than 10 joints 5 points

Wheeless. (2011)
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Serology Test

• At least 1 serology test result is needed for
  classification.
• Negative RF and negative ACPA 0 points
• Low-positive RF or low-positive ACPA 2 points
• High-positive RF or high-positive ACPA 3 points

Wheeless. (2011)
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Acute Phase Reactant Test

• At least 1 test acute-phase reactant test result
  is needed for classification.
• Normal CRP and normal ESR 0 points
• Abnormal CRP or abnormal ESR 1 point

Wheeless. (2011)
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Patient Self Reporting

• Patient-reported duration of synovitis
  signs/symptoms of joints
• Shorter than 6 weeks 0 points
• 6 weeks or longer 1 point

Wheeless. (2011)
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Stage I Rheumatoid Arthritis

• Synovial membrane hyperemic and edematous
• Joint effusions with high cell count
• No destructive changes in X-Rays
• May show swelling or osteoporosis

• Wheeless. (2011)

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Stage II Rheumatoid Arthritis

• Inflamed synovial tissue proliferates and begins
  to grow into joint cavity
• Gradually destroys cartilage
• Narrowing of joints due to loss of cartilage

Wheeless. (2011)
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Stage III Rheumatoid Arthritis

• Pannus of Synovium
• Eroded cartilage and
• exposed sub-chondral
• bone
• X-Rays show extensive
• cartilage loss
• Erosions around margins of the joint
• Deformities may become apparent

• Wheeless. (2011)

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Stage IV Rheumatoid Arthritis

• End-Stage Disease
• Inflammatory process subsides
• Subcutaneous nodules associated with severe
  disease

Wheeless. (2011)
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Clinical Indications

• Clinical/History Data
• Height
• Weight
• BMI
• Temperature
• Food Allergies

Escott-Stump, S. (2008)
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Clinical Indications

• Lab Work
• RBC
• WBC
• C-Reactive Protein
• LE Prep
• Crest (may be decreased)
• ESR (increase w/ inflammation)
• ANA
• Rheumatoid Factor
• Immunoglobulins (Cause of Sjogrens Syndrome)

• Ceruloplasmin (may be increased)
• Hematocrit and Hemoglobin
• Serum Ferritin
• Serum B12
• Transferrin
• Serum Folate, RBC Folate
• Serum Copper
• Albumin, Transthyretin
• Glucose
• BUN
• Ca, Mg, Na, K

Escott-Stump, S. (2008)
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Complications with RA

• Effects on Skin
• Rheumatoid Nodules
• Inflammation of blood vessels can cause skin and
  surrounding tissue to appear as ulcer
• Skin rashes

• Eye Complications
• Inflammation of whites in the eyes
• Scleritis-more serious
• Sjogrens Disease

• Heart and Blood Vessel Disease
• Collection of fluid between pericardium and the
  heart
• Pericarditis
• Lesions on the heart similar to Rheumatic nodules
• Increased risk of heart attack and stroke
• Vasculitis

WebMD. (2011)
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Complications with RA

• Diseases of the Blood and Blood Forming Cells
• Anemia
• High levels of blood platelets
• Feltys Syndrome

• Lung Problems
• Pleuritis
• Rheumatic nodule formation in the lungs
• Interstitial lung disease
• Pulmonary hypertension

• Susceptibility to Infection
• Treatment with biological agents may greatly
  increase the risk of serious infections in people
  with RA

• Emotional Effects
• Depression
• One study showed that almost 11 of all people
  living with RA have moderate to severe depression

WebMD. (2011)
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Treatment

• No known cure as treatment
• Medications
• NSAIDS
• DMARDS
• Biologics
• Steroids
• Therapy
• Physical Therapy
• Occupational Therapy
• Surgery

Nelms, et al. (2010)
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Treatment Goals

• RA gets worse as it progresses so it is important
  to
• Reduce inflammation
• Reduce joint pain
• Protect from cartilage erosion
• Maintaining proper function of joints
• Prevention against growth of rheumatic nodules

Nelms, et al. (2010)
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Medications

• NSAIDS
• Manage chronic pain, inflammation, and swelling
• Aspirin
• Ibuprofen
• Acetaminophen

• DMARDS
• Slow the progression of joint damage
• Rheumatrex
• Arava
• Neoral

Escott-Stump, S. (2008) WebMD. (2011)
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Medications

• Biologics
• Genetically engineered proteins from human genes
• Enbrel
• Actemra
• Humira

• Corticosteroids
• Decrease inflammation and reduce the activity of
  the immune system
• Cortisone
• Prednisone
• Triamcinolone

Escott-Stump, S. (2008) WebMD. (2011)
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Therapy

• Physical Therapy
• Focus on maintaining proper functions of the
  joints
• Stimulating muscles, bones, and joints through
  exercise
• Joint function, muscle strength, fitness level

• Occupational Therapy
• Help you maintain daily functions
• Assess patients ability to perform daily
  activities

Ruderman. 2008
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Surgery

• When there is structural damage, medicines cannot
  fix that
• Pain relief is the greatest benefit to orthopedic
  surgery
• Improving fuctions
• Repairing or replacing of weakened joints may
  help regain strength and activity level

WebMD. (2011)
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Rheumatoid Arthritis Medical Nutrition Therapy

• Reduce effects of pain
• Reduce effects of swelling
• Appropriate diet for Juvenile Arthritis to avoid
  progression into Rheumatoid Arthritis
• Maintain nutritional status
• Avoidance of acid producing foods, saturated
  fats, alcohol, caffeine, sugar and processed
  foods.

Escott-Stump, S. (2008)
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RA Diets

• Vegetarian or Vegan
• Mediterranean and Cretan Style Diet
• Elimination Diet

Smedslund, et al. (2010)
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Vegetarian and Vegan Diet

• High in antioxidants causing a reduction in pain
  and stiffness
• Assist in decreasing risk of heart attack,
  stroke, and clogged arteries

• Smedslund, et al. (2010)

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Mediterranean and CretanStyle Diet

• High in fruits, vegetables, cereals, and legumes
• Low in red meat
• High in fish oil
• Beneficial protective effect due to high levels
  of unsaturated fat and antioxidants

• Smedslund, et al. (2010)

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Elimination Diet

• Based on belief that a food antigen plays a role
  in the pathogenesis of a disease and that its
  elimination from the diet should result in
  symptom improvement
• Removal of potential dangerous foods

• Smedslund, et al. (2010)

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Omega-3 Fatty Acid

• Helps reduce inflammation
• Helps reduce morning stiffness
• Assist in avoidance of NSAIDS
• Omega-3 Fatty Acids found in fish oil help reduce
  joint tenderness
• Help increase mobility
• Fish oil does not slow progression, just treats
  symptoms

Escott-Stump, S. (2008) Nelms, et al. (2010)
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Omega-6 Fatty Acid

• Reduces pain
• Reduces swelling
• Reduces morning stiffness
• May take 1-3 months for benefits to appear

Erlich. (2011)
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Antioxidants

• Antioxidants defend against oxidation which
  damage membranes and cause the swelling
• Reduce pain in joints

Vugt. (2008)
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Vitamin B5

• 2 g/day of Panthothenic Acid
• Reduces morning stiffness
• Reduces pain and severity
• Reduces degree of disability

Erlich. (2011)
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Vitamin B6

• Chronic inflammation may lower Vitamin B6 levels
• Improves immune responses
• Huang clinical study

Erlich. (2011)
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Vitamin C

• Powerful antioxidant
• Serves a role as a cofactor in collagen synthesis
• The main protein in joint tissue and bone.
• Plays a role in fighting infection and may work
  to control inflammation which is linked to
  infection.
• Some believe infection can trigger flares of
  rheumatoid arthritis

Arthritis Foundation (2011)
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Vitamin D

• Low Vitamin D intake has been associated with
  alterations of genes including proliferation
• Decreases extreme RA conditions
• Decrease severity of osteoporosis
• Strengthening bone

Saevarsdottir (2011)
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Vitamin E

• Strong antioxidant
• Assist in avoidance of NSAIDS
• The Womens Health Study

Karlson (2010)
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Selenium

• Deficiency leads to decreased response in immune
  system
• Antioxidant properties that help protect cells
  against free radicals
• Low levels of the mineral may increase the risk
  of developing Rheumatoid Arthritis

Canter et al. (2007) Saccone. (2011)
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Iron

• Anemia is a common problem in patients with
  Rheumatoid Arthritis
• Decreased bone marrow response to EPO
• Reduced EPO levels
• Incurrent infection
• Premature destruction of RBC

Al-Qenaei (2008)
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Copper

• Copper combines with salicylate, a compound found
  in aspirin, and improves the drug's
  pain-relieving ability
• Copper is also essential for the body's
  manufacture of connective tissue, the ligaments,
  tendons and such that wrap around a joint like
  rubber bands and keep it stable.

Ehrlich (2011)
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Current Research

• Many current studies
• Smedslund, et al described a study on
  Effectiveness and Safety for Rheumatoid
  Arthritis
• RA patients as defined by the ARA critera
• Primary outcomes considered were pain, joint
  stiffness, fatigue, functional status and adverse
  affects such as unwanted weight loss or GI
  Problems

Smedslund, et al. (2010)
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Current Research

• The study consisted of 77 patients comparing 4
  weeks on an elemental eating plan with an
  ordinary diet
• Pain Scale
• Physical Function
• Morning Stiffness

Smedslund, et al. (2010)
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Ethical Issues

• MNT not proven to work
• Home prescription
• Supplements
• Medications
• RA diets VS. RA placebo
• Causing erosion

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Conclusion

• No known cure for Rheumatoid Arthritis
• Reduce risk factors that may link to RA
• Nutritional intervention can help slow
  progression and reduce symptoms
• Include many vital antioxidants, essential fatty
  acids, vitamins and minerals in diet

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Questions?