Documente Academic
Documente Profesional
Documente Cultură
FK-Unhas
September 2016
Nutrition in Musculosceletal systems 2016 1 02/09/2018
Based on SKDI 2012,
Level competence : 3A
* osteoporosis
* osteoarthritis
Level competence : 1
• Ricketsia
• Osteomalacia
Level competence :4A
Hyperuricemia, gout
*
Nutrition in Musculosceletal systems 2016 2 02/09/2018
*Nutrient related to musculosceletal system
*Osteoporosis
*Osteoarthritis
*Ricketsia
*Osteomalacia
*Hyperuricemia, gout
*
Nutrition in Musculosceletal systems 2016 3 02/09/2018
*To understand nutrition related to musculosceletal
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
*
Nutrition in Musculosceletal systems 2016 4 02/09/2018
*
*
Nutrition in Musculosceletal systems 2016 8 02/09/2018
* 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.
*
Nutrition in Musculosceletal systems 2016 9 02/09/2018
* The trace elements, calcium and phosphorus, are
highly involved in skeletal growth.
* Paratyhroidhormone (PTH) regulates calcium and
bone homeostatis.
* Magnesium and flouride 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.
*
Nutrition in Musculosceletal systems 2016 10 02/09/2018
Table 1. Some important minerals in the bone
Growth factors
IL-6 Osteoblast Binding protein
Osteoclast
60µm H+ Proteases
Resorption Formation
20 days 160 days
Figure 1. Normal bone remodelling
Rosen C. In: Marcus R, et al. Ed. Osteoperosis, Atlas of Clinical
Endocrinology, volume 3. Blackwell Science Publisher 2000.
*
*
Nutrition in Musculosceletal systems 2016 17 02/09/2018
*
Nutrition in Musculosceletal systems 2016 18 02/09/2018
*Osteoarthritis is a disease characterized by
structural abnormalities at the joint level, a
common health problem in populations over age
40 years.
*It is a leading cause of pain and disability.
*The wrists, hips and spine are mostly affected.
*Osteoarthritis is the most common type of
arthritis.
*
Nutrition in Musculosceletal systems 2016 19 02/09/2018
* 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.
*
Nutrition in Musculosceletal systems 2016 20 02/09/2018
Figure 3. Relationship among osteoarthritis, obesity, physical
inactivity and chronic low-grade systemic inflamation
Nutrition in Musculosceletal systems 2016 21 02/09/2018
Figure 4. Healthy knee joint and osteoarthritis
22 02/09/2018
Nutrition in Musculosceletal systems 2016
* 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.
*
Nutrition in Musculosceletal systems 2016 23 02/09/2018
* 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.
*
Nutrition in Musculosceletal systems 2016 24 02/09/2018
* 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.
*
Nutrition in Musculosceletal systems 2016 25 02/09/2018
*
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* Osteoporosis is the most common
bone disease in humans.
* It is characterized by low bone
mass, structural deterioration and
decreased bone strength.
* The aging population is highly
affected.
* It is silent disease until a fragility
fracture occurs at the hip or
proximal humerus, when significant
physical disability can result.
*
Nutrition in Musculosceletal systems 2016 27 02/09/2018
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)
*
Nutrition in Musculosceletal systems 2016 32 02/09/2018
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
*
Nutrition in Musculosceletal systems 2016 33 02/09/2018
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
*
Nutrition in Musculosceletal systems 2016 34 02/09/2018
Figure 7. Clinical presentation and prognosis of osteoporosis
Normal Osteoporosis
Normal Osteoporotic
DESCRIPTIONS MEANING
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
*
Nutrition in Musculosceletal systems 2016 42 02/09/2018
* 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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* 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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* 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.
*
Nutrition in Musculosceletal systems 2016 45 02/09/2018
* 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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*
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* Gout is a metabolic disorder of
excess uric acid accumulation that
manifests as inflammatory arthritis,
chronic arthropathy, and the
formation of tophi, deposits of
monosodium urate crystals in the
joints and tendons.
* Uric acid is the end product of
purine metabolism.
* Human lost hepatic uricase activity,
this leads to uniquely high serum
uric acid concentrations when
compared with other mammals.
*
Nutrition in Musculosceletal systems 2016 48 02/09/2018
* 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.
*
Nutrition in Musculosceletal systems 2016 49 02/09/2018
Figure 9. Synthesis and excretion of uric acid
Nutrition in Musculosceletal systems 2016 50 02/09/2018
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
*
Nutrition in Musculosceletal systems 2016 51 02/09/2018
Figure 9. The pathogenesis of hyperuricaemia and gout.
Nutrition in Musculosceletal systems 2016 52 02/09/2018
Figure 10. Fructose and uric acid
Source : Pillinger MH et al. Hosp Jt Dis. 2008;66(3):231-9.
Nutrition in Musculosceletal systems 2016 53 02/09/2018
Figure 11. Inflamation stimulate hyperuricemia
Source : Anker SD et al. Circulation 2003;107:1991-7
Nutrition in Musculosceletal systems 2016 54 02/09/2018
*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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