Rheumatoid Arthritis

Case Study F Questions

Rheumatoid Arthritis

1. What is autoimmune disease? How is this immune response different from the normal response to a foreign antigen?

Autoimmune disease is when the body produces antibodies that directly attack against the “self” body cells.  The body produces antibodies to help attack any pathogens that may have enters the body.  When someone has an autoimmune disease, their body has antibodies called autoantibodies that ignore self-antigens.  They do not attack the pathogens because they see the healthy cells as the pathogens and attack them instead.  Normally, the body is infected with a bacterium that spreads from cell to cell.  When that happens, the body produces B cells and when they are stimulated, they differentiate into plasma cells that create the antibodies to attack the bacteria or antigen.  Those B cells replicate each other to destroy the antigen and remain in the body to continually destroy that antigen if it returns.  Autoimmune disorders create B cells that think that the healthy cells are antigens and they attack those cells and replicate additional B cells to continue the attack.1

1. What is the proposed rationale for using antioxidant supplements and omega-3 fatty acids in treating rheumatoid arthritis?

Antioxidants have shown that they can help reduce the number of free radicals that damage the joint linings.  By decreasing that impact on the joints, it can decrease the overall symptoms of pain and swelling.2  The same with using amega-3 fatty acids.  By using fish oil supplements, it can help the body reduce the formations of free radicals that are causing swelling in the joints.  In addition, it can reduce the degeneration of cartilage as well as help with joint stiffness.2

1. Calculate percent usual body weight (UBW), percent ideal body weight (IBW), and body mass index (BMI). Is Mr. Jacobs’s weight of concern? Why or why not.

Mr. Jacobs is 5’10” and currently weights 154 lbs.  However, 2 years ago, he weighed 165 lbs.  His UBW would be 93.3% and the percent of change would be 6.7%.  Mr. Jacobs’ IBW should be 165lb and his current BMI is at 22.1.  At this point, his weight is not a concern but if it was to increase over his IBW, it would become a concern.  This is because any extra weight can cause more complications and pain for his joints.  In addition, I would be concerned if he started to gain weight in a short amount of time and this can also increase his joint pain.2

1. Calculate energy and protein requirements for Mr. Jacobs.

Height = 5’10” = 177.8 cm. Weight= 154lbs = 69.9 kg, 39

Harris-Benedict REE= 66.5+13.8 (W) +5.0 (H) -6.8 (A)

REE= 66.8+13.8(69.9kg) + 5.0(177.8cm) – 6.8(39)

Protein requirement 0.8g per day/weight kg = 55.9 g/day

1. Evaluate the 24-hour recall using computerized dietary analysis and discuss the findings.

When looking at the 24- hour recall, it shows that Mr. Jacobs is only taking in 978 kilocalories.  This is below his base line for energy requirements.  His protein intake is only at 52g which is concerning as this means he is not consuming enough protein to meet his standard for metabolic need.  Other areas of concern for deficiency would be omega 3 fatty acid, calcium, dietary fiber intake, phosphorus, zinc. Potassium, vitamins A, C, ,D, K, thiamin, choline, and folate.  Mr. Jacobs’ does limit his omega 6 fatty intake which can increase inflammation.  In addition, he is sodium intake is too high and he is consuming large amounts of caffeine.  He needs to limit the amount or eliminate it all together as this can interfere with the absorption of calcium.2

1. Mr. Jacobs states that his appetite is fair. What other questions might you ask to further assess his appetite? What are possible causes of his decreased appetite?

When talking to Mr. Jacobs about his appetite, first thing I would ask him would be to please elaborate on what he means by his appetite is “fair”.  In addition, I would ask him if he has noticed any changes in his appetite and if so, what type of changes and when did they start.  Does he limit eating certain foods and if so, why does he feel he needs to?  I would ask him if his pain keeps him from being able to eat at all?  some causes for his decreased appetite should be pain from his joints, knowing that certain foods cause more inflammation, and some medications can cause decreased appetite.2

1. What is the history and rationale for the kosher diet? Does this diet have any nutritional consequences for the patient?

The kosher diet was developed by God’s commandment for the Jews to keep them from developing food illnesses.  A kosher diet is a healthy diet that consists of meats, fruits, vegetables, and dairy but there are specific guidelines as to how the food has to be prepared and what foods can be eaten together.  However, the diet tends to fulfill all of the daily nutritional needs for a patient.3

1. This patient will be started on methotrexate. What are the common drug-nutrient interactions with this medication?

Methotrexate can impacte the person’s intestines ability to be able to absorb nutrients.  The lack of absorbed nutrients can lead to a deficiency in vitamin B12, folic acid, and beta-carotene.  In addition, it can damage the person’s lining in their mouth, intestines, and stomach.  Due to this, production of enzymes needed to process carbohydrates, fats, and proteins can be deceased and should be monitored.4

1. 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?

Looking at the physician’s assessment, they noted temporal wasting and slight muscle wasting along with a slim appearance.  I would use skinfold measurement to analyze the body fat as well as weight circumference, BOD POD, and DXA scans.2

1. What may be the possible reasons for any loss of lean body mass?

Some of the reasons for loss of lean body mass could be the lack of protein intake which causes the body to burn muscle to make the protein.  In addition, the pain of RA patients, they do not receive the physical activity needed to increase their muscle strength which can lead to muscle wasting.  Another reason could be due to the decreased appetite; a low calorie diet can cause an increase in muscle loss.2

1. What laboratory measures correlate with wasting of lean body mass?

Blood test for total protein levels can indicate muscle loss and in addition, urine analysis for creatinine levels can correlate with wasting of lean body mass.5

1. 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.

Blood test to evaluate proteins give an indication of an inflammation response as well as an overall nutritional status.  For a person that is suffering from RA, specific albumin results will show signs of muscle wasting as wells as creatinine levels. When working with RA patients, one should also consider vitamin D blood test, vitamin B 12 and calcium.  This is helpful because it can help determine factors for anemia and osteoporosis due to malabsorption and malnutrition.6