Dealing with anemia & diet in arthritis patients

by Dr. Vaijayanti Lagu – Joshi

“Oh, Doctor, Can I eat everything ? Sour, Cold anything ? No diet restrictions ?” Kamalatai, a patient of Rheumatoid arthritis was surprised, More than arthritis, she was more harassed by hundreds of advices about diet & diet restrictions. The story is more or less similar for all our patients of arthritis, dominantly females between age 30-50 yrs. They have a big questionnaire on what to eat ? what not to eat ? whether arthritis flares up after eating lemon / ice-cream ? Here’s an attempt to explain a few things about anemia in arthritis patients & role of diet in overall treatment.

There are more than 100 types of arthritis out of which rheumatoid arthritis , spondyloarthropathy, systemic lupus erythematosus are multisystemic problems. Apart from joints, they affect rest of the systems like lungs, nerves, blood vesels & blood cells also. Because of the process of ongoing inflammation, the patients show reduced appetite, improper digestion, reduction in weight and the overall effect is deterioration of general health & anemia.

* Anemia is nothing but reduction in hemoglobin (red blood cells) hematocrit. For Indian males, average Hemoglobin (Hb) is 11-16 gm% & for Indian females average Hb is 11-13 gm%. When there is reduction in Hb below these reference ranges it is labelled as anemia. Hb less than 8 gm is labeled as severe anemia & needs immediate work up & attention.

* In patient of arthritis, there are many causes for anemia. As we know, red blood cells are generated in bone marrow. The active ongoing arthritis process sometimes suppresses the bone marrow and red blood cell production which leads to anemia. More commonly, there is deficiency of iron, folic acid, vit B12. in nutrition. The deficiency of these important factors could be either because of lack of nutritious things in diet or wrong dietary habits. In addition there are many myths about about diet for arthritis patients.

Sometimes, loss of appetite, nausea, vomiting due to some anti-inflammatory drugs can impair oral intake of patients. On rare occasions, drugs like sulfasalazine & methotrexate suppress bone marrow resulting in anemia.

In SLE like collagen disorders, there are antibodies formed against red blood cells which cause lysis of RBCS and result in anemia. In some patients of arthritis cause of anemia may be all together different like excessive bleeding during menses, concomitant thyroid, liver or kidney problems, bleeding piles etc.

Well, how do you know about this anemia?

There are general nonspecific symptoms like easy fatique, breathlessness on mild routine activities, loss of appetite, loss of weight, stomatitis, glossitis. Some patients also have flare of arthritis simultaneously.

Some doctors do advise a few laboratory tests of blood. These tests guide us about the degree of anemia & cause of anemia. Once the anemia is detected, the treatment as per the cause is begun. If it is a nutritional deficiency anemia, supplementation of iron, folic acid & B vitamin is started in form of tablets or Injections. It takes 4-6 weeks for the response to be seen. If the cause of anemia is concomitant problem like thyroid, kidney or liver disease, menstrual, piles problems they need attention & proper treatment.

When arthritis patients show anemia with -flace of arthritis, steriods are used for control of inflammation as well as improvement of hemoglobin. The medications of arthritis methrotexate, sulfasalazine are with held or tapered till anemia improves.

Diet – An important element

There are many myths about diet in patients with arthritis. But for good general health & improvement of anemia the patient must pay attention to their diet. Most of the patients feel that non-vegeterian diet, cold, sour things, excess dal worsen arthritis. But there is no scientific evidence for dietary restrictions. So modern medicine does not impose lot of restriction of diet except in a few circumstances like gout, obesity and concomitant illnesses like diabetes.

DIET

Dos :-

1. The diet should be balanced, with involvement of carbohydrates, proteins & limited fats.
2. The diet should be divided into short, small frequent (4-6 times) meals.
3. Drink 3-4 litres of water daily.
4. Drink 1-2 glasses of milk daily.
5. For iron & vitamin supplementation, do include green leafy vegetables, fresh fruits, eggs, soyabean.
6. For non-vegeterians fish & eggs, liver part of chicken are good.

Don’t :-

1. Avoid heavy meals.
2. Avoid excess oily, high fat, high carbohydrate, sweets.
3. No need of boiled water.
4. Avoid sugar / malai with milk.
5. Avoid fasting while on medications.
6. Avoid high fat, carbohydrate diet in obese patients.
7. For gout patients, avoid alcohol, red meat, paneer, cheese, butter, peanuts, tomatoes.
8. Restrict bakery products, rice, potatoes.

To conquer chronic illness like arthritis, patients should take right medicines under right medical supervision and supplement the treatment with right balanced diet, rest & exercises & a positive attitude. That’s how the patients of arthritis can live happily with arthritis.

Use of X-rays, C.T. Scan & MRI for diagnosis

by Dr. Vardhan Joshi

adiology plays an important part in diagnosing and characterizing the type of arthritis. Various radiological modalities come handy for the purpose, however X-ray remains the most basic and most widely used modality.

X-rays can pass through the soft tissues of body, however are variably attenuated by calcium in bones giving rise to excellent pictures of bones, joints and articular surfaces. They also give an indirect idea of joint space and cartilage. In degenerative arthritis, there is joint space narrowing, subarticular sclerosis, erosions and osteophytes formation, while in rheumatoid arthritis there is initially joint space widening with periarticular osteopenia with soft tissues swelling. Slowly, there is joint space narrowing, articular erosion finally leading to ankylosis (bony fusion) and deformities. In psoriosis, there is abonormal bone formation, particularly along the sides of vertebrae with large osteophytes and occasionally bone sclerosis. In ankylosing spondylitis, spine has a “Bamboo” like appearance.

CT scan uses X-ray in a slightly different manner, to obtain thin sections of a body part and are used for evaluation of sacroilic joints, apophyseal joints.

MRI scan is based on imaging with strong magnetic field allowing us to visualize soft tissues like muscles, ligaments, cartilage and synovium like nerves before. It is particularly useful to visualize synovial hypertrophy in RA and to differentiate TB from arthritis. Atlantoaxial joints are also well evaluated with MRI. Sonography has nowdays been used for joint evaluation, particularly for joint fluid, status of capsule, ligaments and muscles.

Arthritis, Obesity & Diet

by Dr. Kalpana Joshi

Many patients diagnosed with osteoarthiritis are overweight and may become overweight as a result of their decreased mobility and / or an inappropriate dietary intake. Weight reduction is an important measure to minimize stress on the joints, to reduce pain and maintain or improve mobility. Osteoarthritis has no specific dietary indications but lack of mobility may hamper physical activity and increase boredom eating. Incidence of the weight bearing joints is higher in obese than in lean persons and this condition worsens with higher weight. For patients with OA weight reduction seems to improve joints.

Overweight is defined as a body mass index (BMI) of 25 to 29.9 and obesity is defined as BMI greater than 30 (NIH, 1998). Body mass index is ratio of weight in Kg to square of height in meters. Following table gives us classification of overweight and obesity, based on BMI.

BMI (Body Mass Index) :
19-24.9 Kg/m2 Normal
25-29.9 Kg/m2 Overweight
30-40 Kg/m2 Obese
>40 Kg/m2 Severely obese

Imbalance in energy input leads to accumulation of fats. Excess energy consumed relative to individual’s energy requirements leads to putting on weight. Complex interactions of factors like excess intake of food, lack of energy expenditure and heredity result in overweight and obesity.

Dietetic management of Obesity

Necessary changes in eating and physical activity together can bring in weight reduction. Calories restriction by giving moderate energy deficit or low calorie diet and increase in physical activity can mobilize the fat stores. Diet should contain variety of patterns like low fat, high carbohydrates to complex carobhydrates and saturated fats to unsaturated fats can bring in the desired effect. Complex CHO are less fattening, because they are much less easily converted to body fat.

Dietary regimens such as low-calorie diet (LCD) with total calorie intake of average 800-1200 kcal/day or very low-calorie diet (VLCD) < 800 kcal/day , also called protein diet could be used under proper medical supervision by moderately or severely obese individuals.

Diet in Osteoarthritis

A well balanced diet that promotes maintenance of desirable body weight is an important medical nutrition therapy for arthrits. Intake of calcium and Vit D should be optimum. High intake of antioxidants, especially Vit C, has shown to be reducing the risk of progression of arthritis. Dietary supplements and complementary therapies have gained popularity as cartilage regenerating and avoiding degeneration. However, there is no scientific basis for their benefits. Supplementation of Glucosamine and Chondroitin sulphate are advocated for providing building blocks for cartilage regeneration and are reported to give symptomatic relief. Products such as vinegar, honey, algal extras and supplements of vitamins C, E, pantothenic acid, selenium and zinc are commonly tried.

Dietary management in RA

Patients with RA are at risk of poor nutrional status. There are no specific indications for diet in RA. Nutrition related problems in RA are anemia and weight gain as a side effect of steroid therapy. Dietary manipulations of type of fats may be beneficial. Epidemiological studies have shown that Omega-3 fatty acids may help prevent rheumatic arthritis. Omega-3 fatty acids are found to be down regulating production of proinflammatory cytokines and modulate the effects of their inflammatory mediators such as eicosanoids. Altering dietary polyunsaturated fatty acids (PUFA) composition in favour of incresed levels of Omega-3 fatty acids could therefore beneficially reduce or mothe inflammatory process and thus reduce symptoms.

Diets with supplemental doses of Omega-3 such as flax oil or almond oil have shown to be effective in improvement in arthritic conditions and modulation of inflammatory response.

Alternative and complementary dietary therapies Strict vegetarian diets have been reported by patients to improve symptons. Total fasting has been shown to result in symptom relief, possibly as a result of reduced production of the chemical mediators of inflammation, but such a practice is also likely to have detrimental effects on nutritional status and can not be recommended.

Ayurved, traditional Indian system of medicine, looks at arthritis as ‘vata vyadhi’ and recommends diets that reduce ‘ama’ by avoiding fermented foods like idli, bread, curd etc. Snehana, agnee deepana, ama pachana are other lines of treatments suggested by Ayurved.

References

1) Manual of Dietic Practice, Third edition, The British Dietetic Association, Blackwell Science
2. Modern Nutrition Health and Disease, Ninth Edition,Ross et al.
3. Food Nutrition and Diet Therapy, Tenth Edition, Mahann et al