The term musculoskeletal

disorder covers any injury,

damage or disorder of the
musculoskeletal system (that
is, muscles, nerves, tendons,
ligaments, joints and bones).

Dynamic interactions between a person with

rheumatic disease and environment

Management of musculoskeletal
conditions is multidisciplinary:
rheumatologists, or orthopaedic
surgeons, rehabilitation, physiotherapy
and occupational therapy, supported
by specialist nurses, orthotics,
prosthetics, podiatry, dietetics and all
the other relevant disciplines.

The normal function of bone

requires an adequate supply of
amino acids for the synthesis of
collagen, the chief component of
the organic matrix; of calcium
and phosphate for mineralization
of the organic matrix; and of
other organic compounds and
mineral elements.

Growth, repair, and

remodeling of the bone
tissue require a precisely
regulated supply of
hormones, vitamins, and
enzymes.

The source of calcium in

optimizing bone health seems to
be important.
Various observational and
epidemiological studies indicate
that consuming milk and other
dairy foods during childhood and
adolescence is a primary
determinant of bone health

Osteoporosis is a condition in
which the bones become less
dense and more likely to
fracture.

Risk factors for developing osteoporosis

thinness or small frame,
family history of the disease
being postmenopausal and particularly having had early
menopause,
abnormal absence of menstrual periods (amenorrhea),
prolonged use of certain medications, such as those used
to treat lupus, asthma, thyroid deficiencies, and seizures
low calcium intake
lack of physical activity
smoking
excessive alcohol intake.

In women with breast

cancer, chemotherapy with
drugs such as
cyclophosphamide and
methotrexate can cause the
ovaries to stop functioning.

Cancer-related bone loss

can occur for many
reasons, including issues
due to cancer therapies,
such as surgery and certain
medications, and
metastatic disease to the
bone.

Surgery: Because the ovaries are

the bodys primary site for
estrogen production, women who
have their ovaries surgically
removed (called an
oophorectomy) experience a
substantial drop in estrogen
production

Radiation therapy to
treat cancers of the
pelvic area is known to
make bones more fragile.

Hormonal therapy: Estrogensensitive tumors are commonly

treated with medicines known as
aromatase inhibitors.
Arimidex (anastrozole), Aromasin
(exemestane), and Femara (letrozole)

In men, a type of prostate

cancer treatment called
androgen-deprivation therapy
suppresses male sex hormones,
including testosterone.

Types of androgen-deprivation therapy include

drugs that suppress testosterone production
such as Lupron (leuprolide) and Zoladex
(goserelin), known as LHRH
(luteinizinghormone-releasing hormone) or
GnRH (gonadotropin-releasing hormone)
agonists, and the drug Firmagon (degarelix),
an LHRH antagonist.
Medicines called anti-androgens, such as
Eulexin (flutamide) and Casodex
(bicalutamide), interfere with the bodys use of
androgens.

Arthritis is a general term for

conditions that affect the joints
and surrounding tissues.
The two most common types of
arthritis are osteoarthritis and
rheumatoid arthritis.

Rheumatoid arthritis (RA)

is an autoimmune
inflammatory disease that
usually involves various
joints in the fingers, thumbs,
wrists, elbows, shoulders,
knees, feet, and ankles.

Rheumatoid arthritis is a
chronic systemic inflammatory
arthritis of auto-immune origin
that affects primarily the
synovial joints, usually in a
symmetrical pattern.

While protein seems to have a

direct anabolic effect on bone, the
relation between protein intake and
bone is further complicated by the
potential negative effect of
overall dietary acid-base
balance.

Urinary calcium has been

found to be increased with
acid-forming foods, such
as meat, fish, eggs, and
cereal, and negatively
associated with plant
foods and is likely
determined by the acidbase status of the total
diet.

Perhaps more concern

should be focused on
increasing the intake of
alkalinizing fruits and
vegetables rather than
reducing protein sources.

Protein intake increases

urinary calcium loss, but
whether negative calcium
balance results will depend
on dietary calcium intake.

Gout Diet

Many cases of gout occur after

eating certain foods or drinking
alcohol. This is because these
foods, and alcohol, contain
certain compounds called
purines which the body
metabolizes into uric acid.

Mechanisms of monosodium urate crystal formation

and induction of crystal-induced inflammation

Nutritional
Status
and
Dietary
Manageme
nt

Essential Components
of Nutritional
Assessment
Nutritional status is
determined by assessing an
individuals nutrition and
health related ABCDEFs.

Anthropometric Measurements
Biochemical Indices
Clinical Indices
Dietary Intake
Environmental Factors
Functional Status
Specific Aspects of Nutritional
Status Assessment for Various
Arthritic and Rheumatoid
Diseases

Environmental Factors
[Environmental factors may
influence intake and
contribute to over- or
malnutrition in individuals,
including the identification
of physical and social
influences on intake]

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases
Patients with RA are often
underweight and
malnourished. Indicators of
malnutrition also include
rheumatoid cachexia, which
involves muscle wasting
that is often replaced with

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases
Medication-related effects
on biochemical indices of
folic acid and iron status are
also common. Some
medications such as
methotrexate also affect
calcium and vitamin D

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases
Impact the ADLs and IADLs as
well as other aspects of
health-related quality of life.
Pain is a common problem in
RA, greatly affecting healthrelated quality of life.

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases:
GOUT

It difficult to obtain accurate

anthropometric measurements. As
the crystals continue to deposit in
the joints, deformities may occur.
Fatness and obesity increase
Risk of developing gout and gout
attacks.

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases:
GOUT

Comorbid diseases also affect

nutritional status. Central
obesity and serum uric acid
levels are associated with
insulin resistance,
hypertension, high serum
lipids, and renal failure.

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases:
GOUT

The greatest complication in

progression of gout is renal
failure and calculi.
Additionally, patients often
have high blood pressure,
dyslipidemia, insulin
resistance, and high blood
sugar.

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases:
GOUT

Determine intake of alcohol,

nonalcoholic beverages, and
purine rich foods. Alcohol
intake is associated with high
serum uric acid.
Adequate hydration is
important if the patient is at
risk for renal calculi.

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases:
GOUT

Important to determine intake of

purine-rich foods because individuals
may be more sensitive to these foods
and have a greater reaction, or they
may be able to take lower drug doses

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases:
GOUT

Nutrition-related biochemical
indices: CRP may be elevated
when systemic inflammation
and fever are present.

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases;
GOUT
Patients with gout are often
prescribed medications for
inflammation and uric acid
control. Drugs that influence
uric acid synthesis or
excretion include probenecid,
sulfinpyrazone, and allopurinol

Specific Aspects of
Nutritional Status
Assessment for
Various Arthritic and
Rheumatoid Diseases;
GOUT

Patients with rheumatic disease are

at risk of compromised nutritional
status for a variety of reasons.
Careful consideration of a patients
nutritional status using basic
principles of assessment, and
addressing problem areas, can
contribute to a patients overall wellbeing.

Specific Aspects of
Nutritional Status
GOUT
Overall balance of
carbohydrates, proteins,
and saturated and
unsaturated fats needs to
be optimal for both your
general health and the
control of gout.

Specific Aspects of
Nutritional Status
GOUT
These would include any
food high in purines: organ
meat, anchovy, some
pulses, beers and stouts,
herring, asparagus, and
the richer meats, to name
but a few.

Drugnutrient interactions can

change both the therapeutic
efficacy of medications and the
nutritional requirements of
patients.

Mechanisms of
Drug nutrient
Interactions
Alteration of
Pharmacokinetics by Food.
Modulation of Biological
Mediators of Rheumatic
Diseases by nutrients.
Change in Nutritional Status
by Drugs

Disease-modifying
Anti-rheumatic Drugs

Medications can deplete or cause

lower levels of certain nutrients.
Methotrexate treatment
decreases folate levels and
corticosteroid treatment can
cause low calcium and zinc status.
Side effects of NSAIDs, such as
ulceration and GI bleeding, can cause
iron deficiency in patients.