Nutrition Considerations for Patients With Rheumatoid Arthritis

March 2015 Issue

Nutrition Considerations for Patients With Rheumatoid Arthritis

The following are nutrition management goals to consider during assessment, diagnosis, intervention, monitoring, and evaluation of patients with rheumatoid arthritis (RA):

achievement of nutritional adequacy and correction of nutrient deficiencies;
management of medication side effects and medication-nutrient interactions;
achievement and maintenance of a healthy BMI while preserving fat-free mass;
prevention or treatment of comorbidities such as cardiovascular disease and osteoporosis;
reduction of pain and inflammation; and
optimization of food-related activities of daily living and quality of life.

Assessment	Reasoning
Body weight/BMI (use more than two indicators if older adult): current weight, recent changes in weight, weight history, BMI, height, waist circumference, and body composition)	• Recent weight loss or gain • BMI less than 20 or more than 30 can affect outcomes and comorbidities
Labs	• Homocysteine, C-reactive protein, albumin, lipid panel, etc • May be affected by level of disease activity or malnutrition
Activities of daily living	• May affect shopping for, preparing, or eating food
Diet history	• History of treating RA with diet • History of weight-loss dieting
Medications	• Nutrition-related side effects such as abdominal pain, stomatitis, weight gain, and ulcers • Drug-nutrient interactions, especially with methotrexate and steroids
Supplements	• Safety and effectiveness • Most not recommended
Fluids	• Meeting recommended targets • Limiting trips to the bathroom because of RA pain
Sex	• Women often affected more severely in all respects
Economic status	• Food insecurity possible
Mental health	• Anxiety or depression often seen with RA
Other

Diagnosis/Comorbidities	Considerations
Level of disease activity	• Can affect labs, resting energy expenditure, activities of daily living, weight, loss of fat-free mass, etc • Can vary over the course of the disease
Cardiovascular disease	• Will likely need intervention to minimize risk
Osteoporosis	• Will likely need intervention to minimize risk • Risk of fracture is higher if long-standing RA, low BMI, or corticosteroid use
Rheumatoid cachexia/weight loss	• Possible loss of fat-free mass • Can affect outcomes and comorbidities
Temporomandibular disorder	• May have difficulty chewing
Sjögren's Syndrome	• May experience dry mouth
Infections	• Higher risk of infection
Other

Intervention	Recommendations
Calories	• Resting energy expenditure may be elevated, but physical activity may be reduced • Additional calories generally unnecessary • Carefully consider appropriateness of weight-loss intervention
Protein	• No clear guidelines • 0.8 g/kg body weight is adequate • 1 to 1.6 g/kg of body weight also suggested for seniors
Fat	• Monounsaturated fat encouraged, no specific amounts • Saturated fat discouraged, no specific amounts • Use of fish or fish oil supplements up to health care provider • To target cardiovascular disease risk, use standard guidelines and address dyslipidemia, if present
Vitamins and minerals	• Use Dietary Reference Intakes as goal • Special attention to folate, calcium, zinc, selenium, and vitamins A, B6, B12, D, and E • Food sources recommended over supplements • Iron supplements not recommended for anemia or chronic disease
Fruits and vegetables	• Address any issues with acquiring and consuming them • Important sources of antioxidants, vitamins, and minerals
Dietary patterns	• Mediterranean, vegetarian, vegan, elemental, and elimination common • No practice guidelines endorsing any specific diet • May be worthwhile if adequacy can be ensured • Individual patients may identify unique problem foods • Makes sense to recommend general healthful eating habits
Barriers	• Diet may be hard to maintain • Unintended weight loss from RA-specific diets • Social influences and family may negatively affect success
Referrals and resources	• Occupational therapist, fitness expert, or other as needed • Websites or health organizations as appropriate (eg, Arthritis Foundation at www.arthritistoday.org, American Heart Association at www.heart.org)
Other