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7.0 Nutritional Management On Musculosceletal Disease 2018
7.0 Nutritional Management On Musculosceletal Disease 2018
Yasmin Syauki
Departemen Ilmu Gizi FK-Unhas
syaukiyasmin@gmail.com
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Nutrition in Musculoskeletal systems 2018 3 08/09/2019
*To understand nutrition related to musculoskeletal
system
*To understand nutrition risk factor and nutritional
management related to osteoartritis
*To understand nutrient and nutritional management
related to osteoporosis
*To understand nutrient and nutritional management
related to gout, hyperuricemia
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Nutrition in Musculoskeletal systems 2018 4 08/09/2019
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Nutrition in Musculoskeletal systems 2018 6 08/09/2019
* The human skeletal systems consists of
bones, cartilage, ligaments and tendons.
* Bones are living, growing and changing
parts of the body.
* Bones :
* cell (2-5% of volume)
* non-living material (95-98% of volume) ≈
mineral encrusted protein matrix -> basic
mechanical properties of hardness,
stiffness and resiliency
* Cortical bone (dense, compact bone) :
* 80% of adult bone mass
* function : to provide strength and stability
* Trabecular bone (spongy bone) :
* 20% of adult bone mass
* predominant in the ends of long bones
* function : to provide strength, stability but
more like shock absorber and lighten
bones.
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Nutrition in Musculoskeletal systems 2018 7 08/09/2019
* There are 3 bone cells :
* osteoblasts : bone cells that initiate the synthesis of new bone
* osteoclasts : bone cells that break down bone and subsequently
release bone minerals into the blood
* osteocytes : osteoblast embedded into the bone matrix
Nutrition in Musculoskeletal systems 2018 8 08/09/2019
* Bone strength is derived from quantity (density
and size) and quality (structure, consistency
and turnover).
* Bone mass is dependent on individual genetic
background.
* Adequate nutrient intake is needed from birth
to achieve maximal bone mass and to prevent
osteoporosis in later life.
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Nutrition in Musculoskeletal systems 2018 10 08/09/2019
* Vitamin D3 plays
important role In calcium
metabolism.
* Vitamin C and K are
cofactors of key enzymes
for skeletal metabolism.
* Sufficientfolic acid and
vitamins B6 and B12 can
help improve bone health.
* Antioxidant nutrients,
including provitamin A
and vitamin C also play a
role in bone health.
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Nutrition in Musculoskeletal systems 2018 11 08/09/2019
* The trace elements, calcium and phosphorus, are
highly involved in skeletal growth.
* Paratyhroidhormone (PTH) regulates calcium and
bone homeostatis.
* Magnesium and floride are matrix constituents.
* Zinc, copper and manganese are components of
enzymatic systems in matrix turnover.
* Selenium as an antioxidant.
* Iron promotes production of collagen in bone
structure.
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Nutrition in Musculoskeletal systems 2018 12 08/09/2019
Table 1. Some important minerals in the bone
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Nutrition in Musculoskeletal systems 2018 16 08/09/2019
Figure 2. Calcium metabolism in the body
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Nutrition in Musculoskeletal systems 2018 22 08/09/2019
* A man, 45 y.o came to clinic because of pain in
the knee. Doctor diagnose him as
osteoarthritis. How to give nutritional
management to him ?
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Nutrition in Musculoskeletal systems 2018 25 08/09/2019
* Obesity is an independent risk factor for
osteoarthritis.
* Biomechanical loading and metabolic
inflammation associated with excess adipose
tissue and lipids may have a role.
* Pain associated with osteoarthritis leads to
increasingly less activity and psychosocial and
physical disability.
* Physical inactivity is an independent risk
factor for inflammation due to the reduced
expression of systemic and cellular anti-
inflammatory mediators.
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Nutrition in Musculoskeletal systems 2018 26 08/09/2019
Figure 3. Relationship among osteoarthritis, obesity, physical
inactivity and chronic low-grade systemic inflamation
Nutrition in Musculoskeletal systems 2018 27 08/09/2019
Figure 4. Healthy knee joint and osteoarthritis
28 08/09/2019
Nutrition in Musculoskeletal systems 2018
* Maintain a normal body weight. If needed,
weight loss may be beneficial to lessen
pressure on weight-bearing joints. Use a
calorie-controlled diet if obesity present.
* Evaluate for sarcopenic obesity, which is
common with knee OA.
* Vitamin D and K play a protective role.
Encourage patient (especially if older) to
consume adequate amounts of vitamin D, and
K, protein and calcium from a healthy,
nutrient-dense, antioxidant-rich diet.
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Nutrition in Musculoskeletal systems 2018 29 08/09/2019
* Maintain integrity of cartilage in affected
joints. Omega-3 fatty acids may reduce the
activity of enzymes that destroy cartilage.
Diets rich in omega-3 fatty acids may reduce
joint stiffness and pain, increase grip strengeth
and enhance walking pace.
* Prevent falls. The risk of falling doubles in
those with lower extremities osteoarthritis.
* Maintain active lifestyle as much as possible.
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Nutrition in Musculoskeletal systems 2018 30 08/09/2019
* Nutraceutical research :
* the most effective : glucosamine, chondroitin, collagen
hydrolysates (CHs), and avocado-soybean unsaponifiables
(ASUs). Piascledine 300 mg (ASU) given once daily is as
effective as chondroitin sulfate 400 mg three times daily.
* Spices and herbs research :
* Curcumin is the yellow pigment isolated from the
rhizomes of Curcuma longa (turmeric). Arantal is a highly
bioavailable curcumin that has shown efficacy.
* An herbal-leucine mixture (HLM) containing extract of
Uncaria tomentosa, Boswellia spp, Lepidium meyenii and
L-leucine has also been found to be an effective anti-
inflamatory agent for OA.
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Nutrition in Musculoskeletal systems 2018 31 08/09/2019
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Age-related bone development
in men and women
I Men
1,500
I III
Bone mass (g/calcium)
Women
1,000
II
III
500
I Peak bone mass
II Rapid bone loss (menopause)
III Age-related bone loss
0
0 20 40 60 80 100
Age (years)
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Nutrition in Musculoskeletal systems 2018 38 08/09/2019
It can be altered
* anorexia nervosa
* current smoking
* depression, past or current
* diabetes
* estrogen deficiency (premature menopause, amenorrhea)
* excessive use of alcohols
* homocysteine, elevated plasma levels
* hypertension
* hypogonadism
* lifetime diet low in calcium (poor diet, excess fiber)
* low testoterone levels in men
* low vitamin D intake or UVB sunshine exposure
* sedentary lifestyle or extended bed rest (immobilization)
* use of chemotherapy, tamoxifen, glucocorticoids, lithium and some
anticonvulsants
* total parenteral nutrition, long-term use
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Nutrition in Musculoskeletal systems 2018 39 08/09/2019
Conditions or diseases that may lead to osteoporosis
* AIDS-HIV
Amyloids
* Ankylosing spondylitis
* Celiac disease
* Chronic obstructive pulmonary disease
* Congenital porphyria
* Cushing syndrome
* Diabetes type 1
* Gastrectomy
* Gaucher disease
* Hemochromatosis
* Hemophilia
* etc
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Nutrition in Musculoskeletal systems 2018 40 08/09/2019
Figure 7. Clinical presentation and prognosis of osteoporosis
Normal Osteoporosis
Dempster DW,systems
Nutrition in Musculoskeletal et al. J2018
Bone Miner Res 1986;1:15–21
44 08/09/2019
http://www.helenhayeshospital.org/rbcmain.html
CLASSIFICATION OF
BONE MINERAL DENSITY LEVELS
DESCRIPTIONS MEANING
WHOinTechnical
Nutrition Report
Musculoskeletal systems Series.
2018 Geneva: WHO,
45 1994 08/09/2019
3250
Projected to
Projected number of osteoporotic reach 3.250
million in
hip fractures worldwide Asia by 2050
668
742
400
378
600
629
1950 2050
Total number of
1950 2050
hip fractures:
1950 = 1.66 million
1950 2050
2050 = 6.26 million
100
1950 2050
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Nutrition in Musculoskeletal systems 2018 48 08/09/2019
* Excess of calcium supplements can cause
hypercalcemia, monitor intakes carefully and
take no more than 500-600 mg (two or more
times daily with meals).
* Avoid taking with iron supplementation.
* Rates of calcium absorption vary and dietary
sources are the best absorbed. Calcium
maleate is also well absorbed.
* Side effects of calcium supplementation may
include abdominal pain, anorexia,
constipation, vomiting, nausea, or dry mouth.
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Nutrition in Musculoskeletal systems 2018 49 08/09/2019
* Space the supplement throughout the day with
meals. Use with vitamin D and magnesium.
* For vitamin D, choose fortified milk, cod liver,
egg yolks and fatty fish. Supplements may be
needed. Do not exceed 10.000 IU/d.
* Extra protein may be needed.
* For sufficient intake of vitamin B12, include
dairy products, meat, poultry, fish and fortified
cereals.
* Isoflavones may be also beneficial, use two to
three servings of soy food daily.
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Nutrition in Musculoskeletal systems 2018 50 08/09/2019
* If patient is obese, use a nutrient-rich,
calorie-controlled diet that provides adequate
protein, vitamins, calcium and others minerals.
* Adequate manganese, vitamins C and K,
potassium and magnesium should be
consumed to meet at least the DRI levels.
Include fruits and vegetables that contribute to
bone health.
* Assure that folic acid and vitamin B6 and B12
are adequate, especially if serum
homocysteine levels are elevated.
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Nutrition in Musculoskeletal systems 2018 51 08/09/2019
* Sodium must be controlled. Keep sodium within desired
limits while increasing potassium and magnesium.
* Beware of excess of wheat bran because phytates may
increase calcium excretion.
* Caffeine from coffee does not seem to be a problem if
calcium (as from milk) is consumed in adequate
amounts.
* Change a sedentary lifestyle. Aerobic and
strengthening exercise will be helpful.
* Decrease the use of tobacco.
* Encourage adequate exposure to sunlight (10 to 30
min/day). Avoid sunburn and overexposure, with its risks
of skin cancer.
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Nutrition in Musculoskeletal systems 2018 52 08/09/2019
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Nutrition in Musculoskeletal systems 2018 54 08/09/2019
* Acute attacks may be triggered by surgery, sudden and
severe illness, fasting, chemotherapy, or joint injury.
* Gout progress from asymptomatic hyperuricemia to acute
gouty arthritis, gout with intervals between acute attacks,
and finally chronic tophaceus gout. Permanent tophi may
develop if the condition goes undertreated.
* Although attacks of gout can subside in a few days,
repeated attacks can cause permanent joint damage, and
the disease often results in substantial disability and
frequent medical care.
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Figure 9. Synthesis and excretion of uric acid
Nutrition in Musculoskeletal systems 2018 56 08/09/2019
Increased urate production Decreased renal excretion of
urate
• nutritional/food : excess • drug : ethanol, cyclosporine,
ethanol or fructose intake, thiazides, furosemide,
meat, seafood ethambutol, pyrazinamide,
• hematological : aspirin
myeloproliferative and • renal : hypertension, polycystic
lymphoproliferative disorders, kidney disease, chronic renal
polycythemia failure
• metabolic/endocrine :
• drugs :ethanol, cytotoxic dehydration, lactic acidosis,
drugs, vitamin B12 (treatment ketosis, hypothyroidism,
of pernicious anemia) hyperparathyroidism
• others : obesity, psoriasis, • others : obesity, sarcoidosis,
hypertriglyceridemia leukimia, toxemia of pregnancy
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Nutrition in Musculoskeletal systems 2018 57 08/09/2019
Figure 9. The pathogenesis of hyperuricaemia and gout.
Nutrition in Musculoskeletal systems 2018 58 08/09/2019
Figure 10. Fructose and uric acid
Source : Pillinger MH et al. Hosp Jt Dis. 2008;66(3):231-9.
Nutrition in Musculoskeletal systems 2018 59 08/09/2019
Figure 11. Inflamation stimulate hyperuricemia
Source : Anker SD et al. Circulation 2003;107:1991-7
Nutrition in Musculoskeletal systems 2018 60 08/09/2019
*A low-fat, high-carbohydrate diet increases excretion of
urates.
* Reduces intakes of beef, organ meats, seafood, pork, bacon
and ham, use more soy-based or meatless meals.
* Nonfat milk, low fat yogurt, dairy products, fruits such as
cherries, and high intakes of vegetable protein may reduce
serum urate.
* Ensure a high-fluid intake, especially water, skim milk and
coffee.
* Exclude alcoholic beverages, fructose or sugar-sweetened
soft drinks.
* Use antioxidant-rich foods such as pomegranate,
raspberries and strawberries.
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KANDUNGAN PURIN DALAM MAKANAN :
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Nutrition in Musculoskeletal systems 2018 62 08/09/2019
* A man, 65 y.o came to clinic because of
stiffness in the toe. Doctors diagnose him has
gout. How to give him nutritional therapy?