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Answer Guide for Medical Nutrition Therapy: A Case Study Approach 3rd ed.
Case 2 – Rheumatoid Arthritis
I. Understanding the Disease and Pathophysiology
1.
Describe the inflammatory response that plays a role in the pathophysiology of rheumatoid arthritis. How do
corticosteroids and NSAIDs interrupt this inflammatory process?
It is proposed that an initial infection may trigger an autoimmune response against the synovial membranes as
well as other tissues. Histamine and other chemical mediators are released as a result of the tissue injury in the
inflammatory response. These chemical mediators result in vasodilation, which increases blood flow to the
injured tissue. Vasodilation results in redness, warmth, and swelling, which are the initial symptoms
experienced by the patient. Pain results from the pressure on surrounding tissues caused by the swelling and
accumulation of blood and other fluids.
Corticosteroids decrease the release of arachidonic acid, which is the precursor to the chemical mediators
involved in the inflammatory response. NSAIDS inhibit the release of histamine, which initiates the
inflammatory response. By decreasing the inflammatory response, the physical symptoms of rheumatoid
arthritis are decreased.
2.
What is an autoimmune disease? How is this immune response different from the normal response to a
foreign antigen?
An autoimmune disease is when the body recognizes its own tissues as “foreign” and produces an inappropriate
immune response. This response is different from the normal response to a foreign antigen because the body
produces autoantibodies in response to self-antigens.
3.
What is the proposed mechanism of methotrexate in the treatment? Relate it to the pathophysiology of an
autoimmune response.
In an autoimmune response, the individual experiences their body’s attack against its own self antigens or
autoantigens. It may involve either the humoral or cell-mediated immune response or both. Methotrexate, as a
cytotoxic agent, would inhibit immune-mediated inflammation.
4.
What is the proposed rationale for using antioxidant supplements and omega-3 fatty acids in treating
rheumatoid arthritis? What does the current research recommend?
Due to the increased oxidative stress involved in the inflammatory process, most research has indicated a need
for increased vitamin E, selenium, folic acid, and zinc. Studies are not consistent in regards to antioxidant
supplementation. The amounts needed for supplementation are not clear and avoidance of consuming more than
10x the DRI should be discussed. Some research studies have shown improvement in disease symptoms with
the use of omega-3 fatty acid supplements. Supplementation may give some relief to RA patients because of the
anti-inflammatory properties. DHA and EPA, found in fish oil, decrease the production of arachidonic acid
derived eicosanoids (mediate inflammation, cytokine synthesis, and cell communication), decrease the
production of pro-inflammatory cytokines (TNF-α, IL-1ß, and IL-6), and decrease lymphocyte proliferation and
reactive oxygen species. Patients need to be advised about the possible side effects of fish oil supplementation
such as decreased platelet aggregation. More studies are needed to determine long-term effects of
supplementation and the minimum dosage required.
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II. Nutrition Assessment
A. Evaluation of Weight/Body Composition
5.
Calculate percent usual body weight (UBW) and body mass index (BMI). Is Mr. Jacobs’s weight of concern?
Why or why not?
%UBW = (154/165) x 100 = 93.3%
BMI = (154/702) x 703 = 22
He is below his UBW and his BMI is at the low end of normal. Though not at the risk of >10% in less than six
months, the weight loss is indicative of potential nutritional risk. This risk can be confirmed with assessing
other nutritional data.
B. Calculation of Nutrient Requirements
6.
Calculate energy and protein requirements for Mr. Jacobs. Identify the formula/calculation method you used
and explain the rationale for using it.
Mifflin-St. Jeor:
10(wt) + 6.25(ht) - 5(age) + 5
10(70) + 6.25(177.8) - 5(39) + 5 = 1621 x 1.1(injury factor) = 1783 x 1.1 (activity factor) = 1961
EER: 1950-2050 kcal/day
0.9 g/kg body weight = 0.9(70) = 63
Protein: 60-70 g/day
Mifflin-St. Jeor has been shown to be an accurate equation for estimating energy needs. However, because
energy needs are altered during disease, such as with rheumatoid arthritis, an injury factor needs to be used.
Because there no information about physical activity in Mr. Jacobs’s exam and he is mostly sedentary at his job,
an activity factor of 1.1 is appropriate.
C. Intake Domain
7.
Evaluate the 24-hour recall using computerized dietary analysis.
The following nutrients are inadequate in the patient’s diet: overall calories, EFAs, fiber, thiamin, folate,
vitamin C, vitamin D, Ca, Mg, K, Zn, and sodium. It may of particular concern that Ca, K, and Zn are low
because his current medications may increase the need for these nutrients. Also, methotrexate may cause an
increased need for folate and calcium. In order to fully assess this patient’s diet, one would need to have a
minimum of 3 days’ intake. Low nutrient intake for one day is generally not a concern. When at least 3 days’
intake is assessed and the inadequate intake is consistent, then a concern can be justified. Additionally, a 24-hr
recall in the hospital may not be representative of his typical intake.
8.
Mr. Jacobs states his appetite is fair. What other questions might you ask to further assess his appetite? What
are possible causes of his decreased appetite?
The RD could ask for more detailed information about food preferences and intolerances. Additionally,
symptoms of nausea, vomiting, diarrhea, constipation, and other physical symptoms need to be identified in
order to determine causes of anorexia. His descriptions of increased pain, drug-nutrient interactions, and lack of
physical activity may all affect appetite.
9.
List possible intake-related nutrition problems that Mr. Jacobs might have by listing the terms that may fit
into the nutrition diagnosis labels.
Inadequate energy intake
Inadequate fiber intake
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Inadequate vitamin intake (A, C, D)
Inadequate mineral intake (Ca, Zn)
Increased nutrient needs (folate)
10. What is the history and rationale for the kosher diet? Does this diet have any nutritional consequences for
the patient?
Kosher foods are those that are prepared according to Jewish Law (Kashrut). The individual determines the
extent of adherence to these laws. Primary restrictions include eating dairy and meat products separately and
avoiding certain meats such as pork and those not slaughtered and processed in a Kosher manner. These dietary
restrictions should make no impact on Mr. Jacobs’s diet as long as he consumes adequate amounts with an
appropriate variety.
11. This patient will be started on methotrexate. What are the common drug-nutrient interactions with this
medication? Are there any other drug-nutrient interactions with his other medications that are of concern?
Explain.
Methotrexate interferes with folate metabolism, resulting in decreased folate stores. It is routine to supplement
with 1 mg folate daily to prevent deficiency. Long-term steroid use may result in hypercatabolism, decreased
calcium stores, and glucose intolerance as well as physical symptoms of nausea and gastritis that might interfere
with oral intake. The regular use of NSAIDS may cause nausea, vomiting, gastritis, and increased risk for peptic
ulcer.
D. Clinical Domain
12. What information in the physician’s assessment may lead you to be concerned about muscle stores? What
additional anthropometric indices might you evaluate to assess muscle mass or lean body mass?
The physician has noted temporal wasting and muscle wasting in the extremities. The RD could assess MAC
and triceps skinfold, and from that data calculate his UAMA or MAMA.
13. What may be the possible reasons for any loss of lean body mass?
His loss of lean body mass may be a side effect of long-term steroid use, lack of physical activity, increased
caloric and protein requirements associated with the disease, and/or poor nutritional intake.
14. What laboratory measures correlate with wasting of lean body mass?
A 24-hr urine collection with assessment of creatinine height index would assess somatic protein stores. The
RD would also want to look at short phase proteins such as prealbumin in order to assess visceral protein status.
15. What laboratory values will be used to assess nutritional status? Are any significant? Are there others that
might be important to assess for patients with rheumatoid arthritis? Explain.
Albumin, prealbumin, hemoglobin, and hematorcrit are all within normal levels. In this patient, hemoglobin and
hematocrit are normal at this admission. Folate levels will be important to monitor when methotrexate treatment
is initiated. This is because methotrexate interferes with folate metabolism and levels are often decreased. In the
future, symptoms of anemia need to be assessed and correlated with possible folate deficiency.
E. Behavioral–Environmental Domain
16. List possible behavioral–environmental nutrition problems that Mr. Jacobs might have. (At this point list
only the terms that are considered the diagnostic labels; do not attempt to write the entire PES statement.)
Food and nutrition-related knowledge deficit
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III. Nutrition Diagnosis
17. For each of the nutrition problems that you identified in this case, complete the entire PES statement. If
there is insufficient data, briefly describe what additional data you would need to make an accurate nutrition
diagnosis.
The following are possible PES statements. It may be helpful for students to initially write more than two
nutrition diagnoses and then prioritize as to the ones that are most likely to have immediate nutrition
interventions.
•
•
•
•
•
•
Inadequate energy intake related to decrease in appetite secondary to food-medication interaction as
evidenced by: refer to question #7 (students should recognize the need to have more detailed objective data
regarding the specific amount of average daily calories compared to recommended 1900-2000 kcal)
Inadequate fiber intake related to infrequent intake of fruits, vegetables, and whole grains as evidenced by:
refer to question #7 (students should recognize the need to have more detailed objective data regarding the
specific amount of average daily grams of fiber compared to recommended)
Inadequate vitamin intake (A, C, D) related to infrequent intake of fruits, vegetables, and fortified dairy
products as evidenced by: refer to question #7 (students should recognize the need to have more detailed
objective data regarding the specific amount of average daily intake of these nutrients compared to
recommended DRI)
Inadequate mineral intake (Ca, Zn) related to infrequent intake of dairy foods and meats as evidenced by:
refer to question #7 (students should recognize the need to have more detailed objective data regarding the
specific amount of average daily intake of these nutrients compared to recommended DRI)
Increased nutrient needs (folate) to 1 g/day related to food-medication interaction of methotrexate. In this
case evidence may not be necessary as the etiology provides enough evidence to validate a nutrition
diagnosis. Evidence can be supported by stating the current intake of folate
Food and nutrition-related knowledge deficit of food-medication interactions as evidenced by patient
inquiring about the use of supplements and other dietary means to manage symptoms of RA
18. Prioritize the nutrition diagnoses by listing them in the order that you expect the interventions to be
developed.
Because there are similar etiologies for a number of the intake ND (inadequate fiber, vitamins, and minerals)
these ND share equal importance and therefore can be considered the highest priority problems. When foods are
added to the diet to meet these nutrients, calories may also increase; thus, inadequate caloric intake may be less
of a concern in the future. Increased nutrient needs of folate, however, may not be met though foods alone and
may require a supplement; thus, this ND would also be a high priority. Last but not least is the ND of
knowledge deficit. Supplements may not be necessary to meet all of the nutrient needs, except for folate and
fish oils, if foods are consumed in appropriate amounts. Food-medication interactions may be a risk with
increased doses of single-nutrient supplements. It will be very important to discuss information about possible
interactions with the patient.
IV. Nutrition Intervention
19. For each of the PES statements that you have identified, establish an ideal goal (based on the signs and
symptoms) and an appropriate intervention (based on the etiology).
•
Inadequate fiber intake related to infrequent intake of fruits, vegetables, and whole grains as evidenced by:
refer to question #7 (students should recognize the need to have more detailed objective data regarding the
specific amount of average daily grams of fiber compared to recommended)
o Goal: Daily average fiber intake of 25-30 grams
o Intervention: Comprehensive nutrition education to include recommended modifications to increase
high-fiber foods (fruits, vegetables, and whole grains).
•
Inadequate vitamin intake (A, C, D) related to infrequent intake of fruits, vegetables, and fortified dairy
products as evidenced by: refer to question #7 (students should recognize the need to have more detailed
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objective data regarding the specific amount of average daily intake of these nutrients compared to
recommended)
o Goals: Daily average vitamin A intake of 900 µg, vitamin C intake of 75 mg, and vitamin D intake of
5 µg
o Intervention: Comprehensive nutrition education to include recommended modifications to increase
nutrient-dense foods providing vitamins A, C, and D, especially dark yellow and orange fruits and
vegetables, citrus fruits, and fortified dairy foods. Supplemental vitamin D may be beneficial in winter
months as well.
•
Increased nutrient needs (folate) to 1 g daily related to food-medication interaction of methotrexate
o Goal: Daily average intake of folate of 1 gram
o Intervention: Comprehensive nutrition education to include recommended modifications of nutrientdense foods providing folate, especially fruits and vegetables and fortified foods. Supplemental folate
may also be necessary to meet the increased needs of 600 µg above the DRI.
•
Inadequate mineral intake (Ca, Zn) related to infrequent intake of dairy foods and meats as evidenced by:
refer to question #7 (students should recognize the need to have more detailed objective data regarding the
specific amount of average daily intake of these nutrients compared to recommended)
o Goal: Daily average intake of calcium of 1000 mg. This is the DRI; however, needs may be increased
due to possible calcium losses secondary to prednisone. Daily average intake of Zn of 11 mg.
o Intervention: Comprehensive nutrition education to include recommended modifications of nutrientdense foods providing calcium and zinc, especially dairy foods and lean meats. Supplemental calcium
may also be necessary to meet the increased needs.
•
Inadequate energy intake related to decrease in appetite secondary to food-medication interaction as
evidenced by: refer to question #7 (students should recognize the need to have more detailed objective data
regarding the specific amount of average daily calories compared to recommended)
o Goal: Daily average caloric intake of 1900-2000 kcal
o Intervention: This may not be a problem as the intake of foods to meet the ND above will also
provide additional calories. Caloric intake will need to be monitored to ensure adequacy over time.
•
Food and nutrition-related knowledge deficit as evidenced by patient inquiring about the use of
supplements and other dietary means to manage symptoms of RA
o Goal: Patient will identify possible food-medication interaction risks associated with high-dose single
nutrients and select appropriate dosage of supplements when scientific evidence supports benefits.
o Intervention: Comprehensive nutrition education to include recommended intakes, upper limits, and
food and nutrient interactions. Patient may also benefit from a list of appropriate peer-reviewed
research articles discussing current trials and results.
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