NUTRITION THERAPY FOR DISEASES OF THE MUSCULOSKELETAL SYSTEM

Quick Study Guide

Prepared by Honey Loveleen R. Bontile, RND, MSPH
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

NUTRITIONAL ACUITY Level 1-3

DEFINITION The musculoskeletal system includes the bones, muscles

and joints. It forms the supporting framework of the body

1. Muscles - responsible for the movement of the

body

1. Cardiac or heart muscle

2. Skeletal or striated muscle
3. Smooth muscles nonstriated muscles of
the gastrointestinal tract, blood vessels,
and other involuntary muscles

2. Component parts of the bones

1. Axial - part of the bones of the trunk which

includes the skull, vertebral column ribs,
and sternum
2. Appendicular - bones of the extremities

3. Tendons aid in locomotion and attach muscles to

the skeleton

DISORDERS OF THE • Rheumatic diseases cover a wide range of diseases

MUSCULOSKELETAL SYSTEM and pathologic processes, most of which affect the
joint tissues and cause symptoms of arthritis.
• The basic structures affected by these diseases are
the connective tissues.
• Those affected are the synovial membrane lining joint
surfaces, cartilage, bone, tendons, ligaments, and
interstitial tissues, in all organs and blood vessels.
• Common forms of rheumatic diseases:

• Rheumatoid Arthritis (RA)

• Osteoarthritis
• Gout
• Systemic Lupus Erythematosus (SLE)

1. ARTHRITIS Inflammation of the joints; types are rheumatoid and

osteoarthritis

1. Rheumatoid Arthritis - a chronic, systemic

inflammatory disease usually occurring in the young
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

adult years. It is a severe type of autoimmune disorder

in which the body’s immune system acts against its
own tissues, mainly the joints of the hands, arms and
feet, causing them to become extremely painful, stiff
and deformed.

Clinical Manifestation

• Tissue changes in the synosheaths. This is the

protective pliable connective tissue surrounding
the body-collagen mesh and fluid that come
together in the synovial area between major bone
heads in joints.
• Destruction of wrist ligaments and tendons,
weakened finger and hand grip strength, and
limited finger movement, all of which limit ability to
self-feed, shop for food and prepare food.
• Elbow and shoulder involvement also hinders
bringing food to the mouth, and further tissue
damage of the temporomandibular joint (TMJ)
limits normal opening and closing of the mouth
and alters chewing ability
• Anemia of chronic disease
• Decreased salivary secretions
• Dysphagia
• Bone disease
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Medical Management

• salicylates, nonsteroidal anti-inflammatory drugs

(NSAID), antimalarial agents, gold salts D-
penicillamine, steroids and immunosuppressive
agents. Aspirin has to be taken after meals to
avoid gastric irritation. STeroids may relieve
symptoms, but excessive or prolonged use can
cause bone demineralization

Nutrition Management

• Early assessment of individual patient status and

needs, especially to detect any degree of
malnutrition
• Assess potential drug-nutrient-food
interactions and their nutritional effects as well as
any of the numerous unproven regimens for
arthritis that the patient may be using
• Dietary supplementation with the omega-3 FA,
eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA) suppress synthesis
of interleukin-1 and tumor necrosis factor, 2
cytokines with potent inflammatory activities
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• Special functional assessment of eating ability

is also needed, including any swallowing problems
involved in the lack of salivary secretions and
dysphagia
• Energy - if the client is receiving physical therapy,
an additional physical activity factor is used.
Increased kcal as needed to achieve desirable
weight gain
• Protein - needs vary with visceral protein status,
surgical therapy, proteinuria and nitrogen balance.
During active inflammatory disease periods,
protein is increased
• Vitamins and minerals - standard
recommendations are used with additional
supplementation of calcium and Vitamin D for
bone disease
• Special enteral and parenteral feeding - tube
feeding may be used either to supplement oral
intake or to supply total nutritional support.
Parenteral nutrition support is seldom used,
except for preoperative and postoperative needs
or when bowel rest is indicated. Continuing
optimal nutritional support is important
maintenance therapy.

B. Juvenile Rheumatoid Arthritis (JRA)

• A form of rheumatoid arthritis, sometimes called

Still’s disease, juvenile chronic polyarthritis, or
juvenile idiopathic arthritis (JIA). It occurs in
children under the age of 15 years old

Clinical Manifestation

• Growth abnormalities – are common and

sometimes leave permanent deformities
• Anorexia - an inflammatory effect that leads to
adipose and muscle tissue breakdown
• Protein Energy Malnutrition
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

• Arthritis
• Splenomegaly - enlargement of the spleen
• Rash
• Involvement of the cervical spine

Laboratory Values

• WBC↑↑, Hgb↓ platelets↑ to ↑↑

• Erythrocyte sedimentation rate (ESR) ↑↑ to ↑↑↑
• Antinuclear antibodies (ANA) and rheumatoid
factor (RF) usually negative; x-ray: soft tissue
swelling

Management

• Nutrition Therapy - continuing nutritional

assessment and counseling are essential to
support growth, malnutrition, weight loss, obesity,
and nutritional anemia
• Medications - NSAIDs, anti-rheumatic drugs and
corticosteroids
• Physical Therapy

C. Osteoarthritis - this type of arthritis is a different

form of joint disease known as degenerative arthritis
or hypertrophic arthritis because inflammation is
minimal
Clinical Manifestation

• Evolves in middle age, becomes chronic, and

may be progressive in its course; mainly
affecting hand and knee joints
• Joint pain limits mobility and use of the hands
• May become a chronic disabling disease in
the elderly
• Destroy cartilage between rubbing heads of
bones in involved joints
• Intermittent pain, swelling and stiffness ,
which occurs at the ends of fingers, thumbs,
neck, lower back, knees and hips

Management

1. Medical Management
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1. Surgical Angioplasty - A surgical

procedure for replacing degenerative
joints such as the hip with mechanical
joints of metal or special plastic;
formation of movable joint
replacement
2. Medications - aspirin, NSAID such as
ibuprofen (Advil, Motrin) or sulindac
(Clinoril) helps relieve symptoms
3. Nutrition Therapy - seeks to ensure a
well-balanced diet and to control
excessive body weight and the painful
pressure on weight-bearing joints.

1. Provide diet rich in Ca, Vit C

&D, thiamine, iron and
riboflavin
2. Low calorie diet if overweight
or obese
3. Increase use of fish and fish oil
(but not fish oil supplements)
owing to the role of omega-3
FA in reducing inflammation
4. Use self-feeding devices to
assist the activity of eating

4. Non-traditional therapy - Acupuncture

DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

2. OSTEOPOROSIS • A bone disease characterized by a reduction

in total bone mass, but with no change in the
structure or chemical composition of the bone
• As a result in the reduced number of bone
cells, there is a decrease in the thickness of
the bone cortex, a thinning of the trabecular,
and an increase in the porosity of the bone
• May be a primary disorder or secondary to
other disease condition

Types of Primary Osteoporosis 1. Type 1 - Postmenopausal osteoporosis

because it occurs most frequently in women.
There is a pain in the vertebrae, rounding of
shoulders, height loss, and susceptibility to
fractures. Best responds to estrogen therapy
2. Type 2 - Senile Osteoporosis because it
occurs mostly in the elderly, more than 70
years old. May respond to increases in
Calcium

Characteristics of Type 1 and Type

Characteristics Type 1 Type 2
2 Osteoporosis
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

Age of Onset 50-70 years 70 years old

old

Bone loss Trabecular Both

bone trabecular
and cortical
bone

Fracture sites Wrist and Hip

Spine

Gender 6 women: 1 2 women: 1

incidence man man

Primary cause Rapid loss of Reduce

estrogen in calcium
women absorption
following increased
menopause; bone mineral
loss of loss,
testosterone in increased
men with propensity to
advancing age fall

Clinical Manifestation 1. Spontaneous fractures

2. Decreased height due to shrinkage of the
spine
3. Stooped posture (dowager’s hump)
4. Muscle tenderness and cramping
5. Weakness

Factors that Influence Bone 1. Heredity

Density 2. Environmental factors - lifestyle, diet, etc
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3. Physiologic factors - age, hormonal balance,

sex, etc

Protective and Risk Factor in

High Risk Factors Suspected
Osteoporosis
Intermediate

Female Low calcium diet FHx of

osteoporosis

Advanced Early menopause

age

White race Chronic thyroid Caffeine

hormone use intake

Thinness Excessive antacid Alcohol in

use moderation

Alcoholism Vitamin D deficiency High protein

Chronic Hyperparathyroidism High fiber

steroid use

Disabling Diabetes (insulin Sedentary

dependent type) lifestyle

Rheumatoid Cigarette smoking

arthritis

Tendency to
fall

Previous hip
fracture
Protective Factors
Estrogen, long Obesity High Calcium
term use

Black Race Having given Physical

birth Exercise

Medical Management • Estrogen replacement therapy

• Two-week cycle with bisphosphonates, a
structural analog of the naturally occurring
pyrophosphate, a component of the
hydroxyapatite crystals forming bone. This
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

depresses the osteoclast activity of resorbing

bone
• 13-week cycle of a daily supplement of 500
mg Calcium and 10ug of cholecalciferol (400
IU of Vitamin D) to ensure that optimal
mineralization occurs during osteoblast
activity

Nutrition Therapy A diet of 1500-2000 mg/day of calcium. The diet

should promote calcium utilization through:

• Adequate, not excessive, protein since

protein favors urinary excretion of calcium
• Adequate Vitamin C and D
• Sodium restriction because when sodium is
excreted, it carries calcium along with it

Physical activity has to be enhanced for weight

control and to sustain the normal bone mass

OSTEOMALACIA Adult form of rickets

Etiology

• Dietary deficiencies of Vitamin D, calcium or

phosphorus
• Inadequate exposure to sunlight (especially
during periods of increased physiologic need
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

as in pregnancy) which is necessary for the

endogenous synthesis of Vitamin D
• Factors that hinder the proper metabolism of
Vitamin D, calcium and phosphorus

Clinical Manifestations

• General Weakness
• Pain

Nutrition Management - Vitamin D, Calcium and

Phosphorus

GOUT A disease of metabolism characterized by

inflammation of a joint (e.g., the big toe)
hyperuricemia and tophi (deposition of urate crystal
around the joints) causing pain
Disease of the Affluent

Predisposing Factors

• Overweight/obesity

1. Alcoholism
2. High dietary purines
3. High-fat diets
4. High fructose diet (provides the
metabolite for purine synthesis)
5. Starvation (tissue proteins are broken
down and yield uric acid)
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Dietary Management
Modification Rationale

Purine-rich foods: Uric acid is derived

restricted from purines

Fat: Restricted Fat retard uric acid

excretion

Protein: Restricted Protein provides the

nitrogen for purine
synthesis

Carbohydrate: Liberal Energy source since

both fat and proteins
are restricted

Fluids: Liberal To promote uric acid

excretion and prevent
urate stone formation

Coffee and tea: These beverages

Moderate contain methylated
purines which are
oxidized to methyl uric
acid and excreted in the
urine, not deposited in
tissues

Daily Food Plan

• DIet should be individualized; a normal diet

contains from 600-1000 mg of purines daily.
In cases of severe or advanced gout, the
purine content of the daily diet is restricted to
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

approx 100 to 150 mg. Use the food grouped

according to purine content listed

Medical management and implications on diet

1. Colchicine - relieves pain but may cause

diarrhea, anorexia. Give with food or milk to
minimize GI effects
2. Uricosuric drugs (Probenecid - promotes
excretion of uric acid)

1. Restricted diet not necessary

2. with long term use, may cause
nausea, vomiting, malabsorption of
sodium, potassium,, fat, carotene,
Vitamin B12 and decrease lactase
activity
3. Maintain adequate diet and encourage
fluids
4. Monitor for effects of malabsorptions;
supplement as needed
5. Limit alcohol

3. Allopurinol - inhibits action of enzyme

xanthine oxidase, which is responsible for the
formation of uric acid from Xanthine and
hypoxanthine

1. While production of uric acid is

decreased, xanthine is increased, and
may cause kidney stones
2. Maintain fluid intake of at least 2000ml
per day
3. May also cause, nausea, vomiting,
diarrhea, metallic, taste, alter, taste,
and iron absorption
4. Give symptomatic treatment
5. With prolonged use, iron supplements
may be needed

Systemic lupus erythematosus • the most common type of lupus.

(SLE) • an autoimmune disease in which the immune
system attacks its own tissues, causing
widespread inflammation and tissue damage
in the affected organs.
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

• It can affect the joints, skin, brain, lungs,

kidneys, and blood vessels.

Other Types of Lupus:

• Cutaneous lupus erythematosus: This type

of lupus affects the skin — cutaneous is a
term meaning skin. Individuals with cutaneous
lupus erythematosus may experience skin
issues like a sensitivity to the sun and rashes.
Hair loss can also be a symptom of this
condition.
• Drug-induced lupus: These cases of lupus
are caused by certain medications. People
with drug-induced lupus may have many of
the same symptoms of systemic lupus
erythematosus, but it’s usually temporary.
Often, this type of lupus goes away once you
stop the medication that’s causing it.
• Neonatal lupus: A rare type of lupus,
neonatal lupus is a condition found in infants
at birth. Children born with neonatal lupus
have antibodies that were passed to them
from their mother — who either had lupus at
the time of the pregnancy or may have the
condition later in life. Not every baby born to a
mother with lupus will have the disease.
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

POPULATION COMMONLY • Anyone can have lupus.

AFFECTED • It can happen to women, men, children and
even newborns.
• It’s much more commonly seen in women
than men, with about 90% of diagnosed
cases being women of reproductive age.
Experts have a difficult time estimating how
many people in the United States have lupus
because it is difficult to diagnose.
• Lupus has a wide variety of symptoms that
can also be signs of other medical conditions.
Because of this, there may be people with
lupus who go undiagnosed throughout their
lives.

• Lupus is also more prominent in certain

ethnicities.
• African-American, Hispanic, Asian and Native
American women are all more likely to
develop the condition than Caucasian
women.
• Your risk of having lupus is also increased if
you have a family member with lupus or
another autoimmune disease.

CHARACTERISTICS Lupus can impact many different parts of your body.

It can cause aches and pains, as well as serious
complications to your major organs. Because lupus is
an autoimmune disease, it causes your body to
attack itself. This can lead to organ damage over
time.
Parts of the body that can be impacted by lupus

• Skin: Skin problems are a common feature of

lupus. Some people with lupus have a red
rash over their cheeks and the bridge of their
nose. Because the location of this rash is the
same as the common markings of a wolf, the
name "lupus" (wolf in Latin) was given to this
disease many years ago. Other skin problems
that may happen include large red, circular
rashes (plaques), which may scar (called
discoid lupus). Skin rashes are usually made
worse by sunlight. Hair loss and mouth sores
are also common.
• Blood: Blood involvement can happen with or
without other symptoms. Individuals with
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

lupus may have dangerous reductions in the

number of red blood cells, white blood cells or
platelets (cells that help clot the blood).
Sometimes, changes in blood counts may
contribute to symptoms of fatigue (low red
blood cell count, anemia), serious infections
(low white blood cell count), or easy bruising
(low platelet count). However, many people
do not have symptoms that indicate blood
abnormalities, so it’s important to have
periodic blood tests in order to detect any
problems. Blood clots are seen with increased
frequency in lupus. Clots often happen in the
legs (a vein clot, called deep venous
thrombosis), lungs (a lung clot, called
pulmonary embolus), or brain (stroke). Blood
clots that develop in lupus patients may be
associated with the production of
antiphospholipid antibodies. These antibodies
are abnormal proteins that may increase the
tendency of the blood to clot.
• Joints: Arthritis is very common in people
who have lupus. There may be pain, with or
without swelling. Stiffness and pain may be
especially uncomfortable in the morning.
Arthritis may be a problem for only a few days
to weeks or may be a permanent feature of
the disease. Fortunately, arthritis is usually
not crippling.
• Kidneys: Kidney involvement in people with
lupus is potentially life threatening and may
occur in up to half of lupus patients. Kidney
problems may become apparent when lupus
patients feel ill with arthritis, have a rash,
fever and weight loss. Less often, kidney
disease may happen when there are no other
symptoms of lupus. Kidney disease itself
usually doesn’t produce symptoms until it’s in
the advanced stages. It is important that
kidney disease be diagnosed early and
treated appropriately. The earliest signs of
kidney disease are apparent from a urine test
called urinalysis.
• Brain: Fortunately, brain involvement is a
rare problem in people with lupus. When
present, it may cause confusion, depression,
seizures and, rarely, strokes.
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

• Heart and lungs: Heart and lung involvement

is often caused by inflammation of the
covering of the heart (pericardium) and lungs
(pleura). When these structures become
inflamed, you may develop chest pain,
irregular heartbeat and build up of fluid
around the lungs (pleuritis or pleurisy) and
heart (pericarditis).

RISK FACTORS • Hormonal changes: Women are more likely

to experience lupus than men and this could
be partly due to hormones like estrogen.
Lupus is often seen in women during their
reproductive years (ages 15 to 44) when
estrogen levels are higher.
• Environmental factors: Different aspects of
your environment can also increase your risk
of having lupus. Factors like the amount of
sunlight you’re exposed to, medications you
take, viruses you might have been exposed
to, or even stress, can all be possible causes
of lupus. A history of smoking can also be a
possible cause of lupus.
• Family history: There may be a genetic
factor to lupus. If you have family members
who have lupus, your risk of the disease is
increased.

SIGNS AND SYMPTOMS Symptoms of lupus can include:

• Joint pain.
• Muscle pain.
• Rashes.
• Fever.
• Sensitivity to sunlight.
• Hair loss.
• Mouth sores.
• Dry eyes.
• Fatigue.
• Chest pain.
• Stomach pain.
• Shortness of breath.
• Swollen glands.
• Headaches.
• Confusion.
• Depression.
DISORDER/DISEASE Disease/Disorder of the Musculoskeletal System

• Issues with the kidneys, heart or lungs.

• Seizures.
• Blood clots.
• Anemia.
• Raynaud’s phenomenon.

CRITERIA FOR DIAGNOSING SLE

NUTRITIONAL MANAGEMENT • People with lupus should aim for a well-

balanced diet that includes plenty of fruits,
vegetables, and whole grains.
• It should also include moderate amounts of
meats, poultry, and oily fish.
• Following a varied, healthy diet may help
reduce inflammation and other symptoms.

MEDICAL MANAGEMENT • SLE treatment consists primarily of

immunosuppressive drugs that inhibit activity
of the immune system.
• Hydroxychloroquine and corticosteroids (e.g.,
prednisone) are often used to treat SLE.