Placing a greater emphasis on early identification and correction of nutritional alterations may greatly benefit those with rheumatologic conditions, according to researchers in Mexico. They report that treating and preventing nutritional alterations may help improve both quality of life and outcomes.
“[Both those with] rheumatologic [conditions] and their diseases are complex. They are highly prone to [have] malnutrition syndromes, including obesity, and these clinical conditions impact negatively their clinical course and prognosis. Early and timely identification of risk factors for malnutrition could help avoid or prevent such conditions, and in patients in whom nutrition alterations are already present, interventions can help limit or reduce their clinical impact and deleterious consequences,” said Gilberto Fabian Hurtado-Torres, MD, MEd, who is an associate professor of internal medicine and clinical utrition at the University of San Luis Potosí, San Luis Potosí, Mexico.
Dr Hurtado-Torres and colleagues maintain that including nutrition professionals in the multidisciplinary care team is the best approach to improving the overall quality of care in this highly vulnerable population. They found that nutritional alterations occur in 4% to 95% of those with rheumatologic disease, depending on the detection method used.1
In the past, a single term was used for all nutritional alterations; all were classified as rheumatoid cachexia. That is no longer the case. Nutritional alterations can now be categorized according to their physiopathologic mechanisms. These include chronic disease-related inﬂammatory conditions, which are classified as cachexia. A second category is malnutrition associated with acute malnutrition inﬂammatory conditions, and a third category is starvation-related malnutrition.
The clinical manifestations of malnutrition associated with rheumatic disease may include being underweight, overweight, or obese, resulting in lean body mass depletion as well as functional repercussions. All of these conditions affect quality of life and are associated with significant morbidity.
“The main problem is not related to clinicians doing things right or wrong. It is mainly a structural problem, [resulting from] lack of knowledge about nutritional aspects [among] the majority of clinical specialists, rheumatologists included. We have to underscore that nutritional topics are not included in postgraduate courses, so specialists are unaware of the importance of clinical malnutrition syndromes and their incidence, prevalence, and impact,” Dr Hurtado-Torres told Rheumatology Advisor.
Measuring Much More Than Just Body Mass Index
The appropriate assessment of nutritional status in those with rheumatologic disease requires the use of nutritional screening scales, anthropometric measurements, dietary history, interpretation of biochemical parameters, and functional evaluation.
Analyzing body composition and using computed tomography scans, magnetic resonance imaging, and muscle ultrasound images may also be beneficial, but just looking at body mass index is not adequate to detect nutritional alterations. In addition, clinicians must factor in the potential side effects of the medications used to treat rheumatic disease, such as immunosuppressants and glucocorticoids.
“There are a lot of scientific works about nutritional alterations in [those with] rheumatologic [disease], but from my knowledge, there is lack of a unified approach or dedicated clinical guidelines oriented to this particular population. Clinical guidelines and statements of clinical nutrition professional societies like the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism, particularly those oriented to malnutrition syndromes, help us systematize and orient our approaches, although we have to extrapolate their principles and recommendations to the specific population we face, because these guidelines are designed to cover a myriad of clinical conditions and are not specific to [those with] rheumatologic disease,” said Dr Hurtado-Torres.
Collaboration Considered Key to Improve Outcomes
He asserted that it is paramount for rheumatologists to work closely with dietitians who specialize in this patient population. Unfortunately, that is not always as simple as it sounds, according to Connie Diekman, MEd, RD, who is the Director of University Nutrition at Washington University in St Louis, Missouri. She said that there are significant barriers to effective collaboration.
“As a registered dietitian (RD), one of the major barriers to getting patients with rheumatoid arthritis the nutritional care they need is the lack of insurance coverage for RD visits. Rheumatologists are focused on the medical care of their patients and while this might include mention of the role of nutrition, their time and expertise in the specifics of nutrition are limited, and referral to an RD would provide the nutrition education and support [patients with] RA need,” Ms Diekman told Rheumatology Advisor.
She said that adequate nutritional status is important to maintain both a healthy immune system and overall health, but that this important issue can easily be overshadowed by management of the disease. “The patient is more than just their RA. Tissue loss is a consistent component of RA and a factor that can lead to muscle wasting if not addressed early and throughout care.”
RA triggers increased metabolism and as the disease progresses, wasting is inevitable, so starting nutritional care early in diagnosis can help prevent this loss and preserve quality of life. Inflammation associated with RA also impacts metabolism and can further impact loss of muscle mass and associated body wasting.
She said that many of the medications commonly prescribed for rheumatologic conditions can have an impact on nutrient absorption, leading to low levels of vitamins and minerals. Clinicians must also consider a patient’s age at the time of diagnosis.
“Age matters in the management of RA nutrition, in that age, in and of itself, causes muscle wasting,” Ms Diekman pointed out. “As people age, muscle regeneration is decreased, so adding the complications of RA on top of natural loss puts patients with RA at higher risk for sarcopenia. Younger patients [with RA] need to focus on nutrition and prevention of deficiencies to keep their bodies healthy in hopes of preventing the cachexia that so commonly occurs with RA”.
The Academy of Nutrition and Dietetics outlines a clear clinical nutrition management plan for those with rheumatic disease.2 Ms Diekman said the treatment plan focuses on assessment of client history, nutritional status, biochemical status, physical state, and life situation.
Based on these factors, a plan for nutrition intervention is developed. Anyone who has rheumatic disease should undergo a preliminary nutrition assessment to determine nutritional needs to develop the best plan to preserve muscle mass and overall health.
Taking Dietary Advice From the Internet
Lona Sandon, PhD, RDN, who is the Program Director and an Assistant Professor in the Department of Clinical Nutrition at the University of Texas Southwestern, Dallas, Texas, said that as an RD and someone with rheumatic disease, she has noticed an interesting trend.
“I have been living with RA for over 20 years. In my opinion, one of the biggest barriers is fear of the many prescribed drugs and their side effects. People are reluctant to take them and want to find natural alternatives such as special diets or dietary supplements. Therefore, they may not be getting medical treatment that could slow down the detrimental effects of systemic inflammation on lean muscle tissue,” Dr Sandon told Rheumatology Advisor.
A significant number of those with rheumatic conditions get much of their information from Internet sources, and that can lead to a host of problems. “It is also my experience that rheumatologists rarely address issues related to nutrition and how nutrition may play a role in the treatment of RA or rheumatic cachexia. There is a lack of referrals to RD nutritionists in this area. This leaves patients searching the Internet, ripe for misinformation,” he indicated. “This might lead them to try highly restrictive diet plans that are limited in essential nutrients and adequate high-quality protein.”
Summary and Clinical Applicability
Lean muscle tissue is not commonly assessed in those with rheumatologic conditions. As a result, when a patient starts to lose lean tissue, there is no baseline for comparison to determine the severity of loss. Another factor is often lack of physical activity or any type of muscle building activity in this patient population. This further exacerbates the cachexic condition.
“Studies have found nutritional deficiencies in [patients with] RA that include vitamins C, D, B-6, B-12, and E, and mineral deficiencies such as calcium, magnesium, zinc, and selenium. We need clinical trials to show whether correcting these deficiencies improves or lessens the effects of cachexia,” said Dr Sandon. “It is a matter of quality of life for the patient. A patient who can maintain lean muscle tissue and strength for a longer period of time will likely have a better quality of life and higher functioning.”
Limitations and Disclosures
Gilberto Fabian Hurtado-Torres, who commented in this story, has no financial disclosures relating to the subject of these comments.
Connie Diekman, who commented in this story, has no financial disclosures relating to the subject of these comments.
Lona Sandon, who commented in this story, has no financial disclosures relating to the subject of these comments
1. Hurtado-Torres GF, González-Baranda LL, Abud-Mendoza C. Rheumatoid cachexia and other nutritional alterations in rheumatologic diseases. Rheumatol Clin. 2015;11(5):316-321.
2. Duncan K. Nutrition and Rheumatoid Arthritis. Today’s Dietitian. 2015;17(3):50. http://www.todaysdietitian.com/newarchives/031115p50.shtml. Published online March 1, 2016. Accessed June 27, 2016.