RHEUMATIC DISEASES
Gout (Arthritis Urica)
Adults
Best time to refer to the dietician:
- Diagnosis of gouty arthritis (artritis urica), sometimes combined with excessive weight (overweight or obesity).
Relevant information for the dietician:
- Diagnosis: of gouty arthritis (artritis urica), or gouty arthritis combined with overweight or obesity, any comorbid conditions
- Symptoms: joint inflammation, tophi
- Medication: diuretics, antigout drugs
- Other: height, (changes in) weight
Aims of the diet:
- reduce symptoms by lowering the amount of uric acid production and/or by promoting its excretion
Characteristics of the diet:
- For excessive weight (BMI > 25 kg/m2): see “Overweight”
- Purine restriction: avoid products with > 150 mg purine per 100 g (based on the higher risk of acquiring gout when intake is high)
- Extra fluids: 2-3 L drinking fluids distributed throughout the day
- Alcohol: no more than 1 unit per day, preferably at least 3 alcohol-free days per week
Treatment time:
- Care level 1, see “Dietician’s working methods.”
Specific remarks:
- Weight loss must be gradual, no more than ½ kg per week (rapid weight loss will increase uric acid production).
- How purine from foods contributes to uric acid production is individually determined.
References:
Hayman S, Marcason W. Gout: Is a Purine-Restricted Diet Still Recommended?
Journal of the American Dietetic Association 2009
Jordan KM, Cameron JS et al. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout. Rheumatology 2007;46:1372–74
Schulten P, Thomas J et al. The role of diet in the management of gout: a comparison of knowledge and attitudes to current evidence. Journal of Human Nutrition and Dietetics 2009; 22:3–11
Zhang W, Doherty M et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee For International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2006;65:1312-24
Gouty Arthritis (Arthritis Urica) was updated by Nicole de Roos, coordinator of research at the Alliantie Voeding Gelderse Vallei and teacher at Wageningen Universiteit, and Helena Smit, dietician / policy worker at the Nederlandse Vereniging van Diëtisten (NVD).
Rheumatoid Arthritis
Adults
Best time to refer to the dietician:
- Diagnosis of rheumatoid arthritis combined with at least one of the following:
- unwanted weight loss of more than 5% in a 1-month period or more than 10% in a 6-month period and/or excessively low body weight (ages 18-65: BMI < 18.5 kg/m2 and > 65: BMI < 20 kg/m2)
- unwanted weight gain
- when a dietary assessment for micronutrients and for completeness of nutrition is wanted
- when chewing and/or swallowing difficulties hinder food intake
- when stomach and/or intestinal disorders (problems with function) hinder food intake
- when skin lesions don't heal well
- when the patient wishes to have dietary advice
Relevant information for the dietician:
- Diagnosis of rheumatoid arthritis + duration of illness, exacerbation/tranquil phase, relevant complications, any comorbid conditions
- Symptoms: changes in weight, gastroïntestinal symptoms, chewing and/or swallowing problems, dry mouth, pain, anorexia, poor healing of skin lesions, micronutrient deficiencies (in the body), osteoporosis, renal insufficiency, diabetes mellitus, iron deficiency anemia
- Laboratory tests: ESR, CRP, albumin, relevant micronutrients such as iron, creatinine, urea, HbA1c
- Medication/Treatment: analgesics, DMARDs, (e.g. corticosteroids and methotrexate), anticytokine therapy
- Other: height, (changes in) weight, mobility
Aims of the diet:
- reduce symptoms
- maintain/achieve a healthy body weight
- maintain/improve nutritional status
Characteristics of the diet:
- Micronutrients: vitamin B1, B6 and B12, iron and folic acid based on recommended allowance. If corticosteroids are being used: supplementation of vitamin D and calcium (a minimum of 1500 mg including preparations).
- For other conditions, such as pressure ulcers, dysphagia, weight loss / malnutrition, diabetes mellitus, overweight condition, chronic constipation or diarrhea: see the relevant disease description.
Treatment time:
- Care level 1, see “Dietician’s working methods.”
Specific remarks:
- It is important to ascertain whether dietary advice or supplements were obtained previously from conventional, alternative and/or unofficial sources with the aim of reducing rheumatic symptoms
- There is not sufficient evidence that a vegetarian diet, a Mediterranean diet or an elementary diet reduce the symptoms.
- There are sufficient indications that fish oils in a dosage of at least 2.7 g per day for a minimum of 3 months can reduce pain and morning stiffness in patients.
References:
Bijlsma JWJ, Voorn TH B (red.). Reumatologie. Houten: Bohn Stafleu Van Loghum: 2000
Firestein GS, Panayi GS, Wolheim FA, Rheumatoid arthritis: New frontiers in pathogenesis and treatment. Oxford: Oxford University Press: 2000
Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain 2007;129:210-223
Hagen KB, Byfuglien MG et al. Dietary interventions for rheumatoid arthritis (Review). The Cochrane Library 2009, Issue 4
Rheumatoid Arthritis was updated by Nicole de Roos, coordinator of research at the Alliantie Voeding Gelderse Vallei and teacher at Wageningen Universiteit, and Helena Smit, dietician / policy specialist at the Nederlandse Vereniging van Diëtisten (NVD).