Nutritional Management

Rheumatoid Arthritis
Yanti Ernalia
 Asupan Energi
Enteral parenteral suplementation may be required
in when intakes are poor
Home nutritional support is beneficial for chronic
disease
Meningkatnya respon metabolik pada saat terjadinya
inflamasi mennyebabkan meningkatnya kebutuhan
gizi pada pasien RA
Pada RA harus memperhatikan perubahan berat
badan. Penderita RA dapat saja obese dan memiliki
kandungan vitamin yang abnormal dalam tubuh
Modifikasi asupan energi untuk mencapai berat
badan ideal
 Protein
Kebutuhan protein pada pasien yang
memiliki status gizi kurang dan dalam
keadaan fase inflamasi dapat meningkatkan
asupan protein 1,5-2 g / Kg berat badan
Kalau pasien dengan status gizi baik sesuai
dengan RDA atau AKG
Pada pasien RA terjadi peningkatan
penmecahan protein yang berkorelasi
dengan produksi faktor growth
hormone,glukagon,dan nekrosis tumor.
 Asam lemak
Asam lemak menurut panjang rantai karbon :
- Asam lemak rantai pendek: 4-6 atom karbon
- Asam lemak rantai sedang: 8-12 atom C
- Asam lemak rantai panjang : lebih dari 12 atom c
a.SAFA
b. MUFA : Asam palmitoleat, asam oleat
c. PUFA :Asam linoleat, asam oleostarat, asam
arakhidonat

1. Asam lemak jenuh: padat

2. Asam lemak tidak jenuh: cair (minyak) atau sangat lunak
(margarin)
 Asam lemak
1. Asam lemak non essensial
2. Asam lemak essensial: dari makanan, terutama
minyak nabati: minyak jagung, minyak kacang,
minyak kedele, dan minyak biji kapas
. Linolenat/Oleat : omega 3: olive oil,lemak
hewani
. Linoleat : omega 6 ; minyak jagung, minyak
kapas,alpokat, kacang,minyak kapas,lemak
ayam
. Arakhidonat: omega 9: minyak kcg tanah,lmk
hewani
 Lemak
Bukan menghindari makanan sumber
lemak
Mengatur komposisi asupan lebih
baik
Minyak ikan dapat menghambat
konversi AA menjadi eikosanoid
 Vitamin dan mineral
Pasien RA banyak seringkali /banyak
yang kekurangan asupan
kalsium,asam
folat,vitaminE,zinc,selenium,piridoksi
n,magnesium
Kebanyakan pada pasien RA memiliki
gangguan patofisiologi stress
oksidatif
Dengan antioksidan dapat
mengurangi nyeri pada pasien RA
 Vitamin dan mineral
Malbsorpsi kalsium dan vitamin D
dan demineralisasi tulang adalah
tahap advabce dari RA yang dapat
menjadi osteoporosis
Methotrexate dapat menyebabkan
penurunan asam folat.
Walaupun pada usia lanjut serum
ferritin menurun namun tidak ada
kebutuhan spesifik dari suplementasi
besi
 Nutritional Management
Balanced Diet
Enteral /Parenteral suplementation
Home nutrition support
Avoidance of possible food allergen
Vitamin D and calcium with prednisson
Fasting Followed by vegetarian diet
Increased omega 3 Fatty Acids
Alternative and complementary therapy
with folic acid with methotexate therapy
Rhemato
id
arthritis
(RA)
Wordsworth P,
http://www.ELS.net
Rhematoid arthritis (RA)
Wordsworth P, http://www.ELS.net

Typical rheumatoid joint deformities. Wasting of

the small muscles, swelling of the
metacarpophalangeal joints and a small
subcutaneous nodule on the little finger. The
fingernail clubbing is characteristic of the
pulmonary fibrosis from which this patient also
 Organ-affections with RA
Joints & muscles
Normochrome anemia
Cardiovascular diseases - vasculitis, etc
Sclerodermia malacia
Peripheral neuropathy
Osteoporosis
Infections
Failure of internal organs
 Dietary prevention/treatment
of RA
Little food
Energy deficiency --> inflammation
Vegetarian diet J Kjeldsen- Kragh
Vitamin D Cantorna MT, Mahon BD. Mounting evidence for
vitamin D as an environmental factor affecting autoimmune disease
prevalence.
Exp Biol Med (Maywood), 2004;229:1136-42

N-3 fatty acids Berbert AA et al. Supplementation of fish oil

and olive oil in patients with rheumatoid arthritis. Nutrition. 2005;21:131-6
 Mounting evidence for vitamin D as an
environmental factor affecting autoimmune
disease prevalence
Cantorna & Mahon; Exp Biol Med, 2004;229:1136-
42
Low vitamin D status has been associated with
autoimmune diseases like multiple sclerosis, rheumatoid
arthritis, insulin-dependent diabetes mellitus, and
inflammatory bowel disease
Optimal level of vitamin D intake for immune function is
unknown but is likely to be at least that required for
healthy bones
Experimentally, vitamin D deficiency results in increased
incidence of autoimmune disease
Mechanistically, data point to a role for vitamin D in the
development of self-tolerance
1,25-dihydroxy vitamin D3 regulates T helper cell (Th1)
and dendritic cell function while inducing regulatory T-cell
function. The net result is decreased Th1-driven
autoimmune response and reduced symptoms
 Vitamin D & immune
response
Holick MF, J Nutr. 2005;135:2739S-48S

Activated T and B lymphocytes,

monocytes, and macrophages have a
VDR
1,25(OH)2D interacts with its VDR in
immune cells and has a variety of
effects on regulating lymphocyte
function, cytokine production,
macrophage activity, and monocyte
maturation
Thus, 1,25(OH)2D is a potent
Vitamin D har mange
effekter
Holick MF, J Nutr. 2005;135:2739S-48S
 Clinical trials on rheumatoid
arthritis w/n-3 FA
Rheumatoid arthritis is improved w/n-3 FA
morning stiffness and number of swollen joints
Fortin et al. J Clin Epidemiol. 1995; 48: 1379-1390.
Less swollen joints & morning stiffness
N-3 FA should be used for > 12 weeks, > 3
g/day
Kemer, Am J Clin Nutr 200, 71 (1 Suppl), 349S-351S
There is a controversy with new metanalyses
 Betaine HCL Many individuals with RA are deficient in
stomach acid and other digestive factors. Supplementation
with betaine HCL with meals will aid in protein digestion and
possibly reduce food sensitivities through improved digestion.
Copper Copper is a component, along with zinc, in one type of
superoxide dismutase. Deficiency may result in significant
susceptibility to free radical damage as a result of decreased
SOD levels.
of copper may be detrimental due to copper's ability to
combine with peroxides and damage joint tissues. Take 2 mg.
daily.
DLPA (D,L-phenylalanine) DLPA is a mixture of the natural
form of phenylalanine (the L form) with its mirror image (the D
form). The D form has been shown to be an effective pain
reliever against the chronic pain of osteoarthritis, rheumatoid
arthritis, low back pain and migraine headaches. It appears to
inhibit the breakdown of endorphins, thereby increasing the
effectiveness of the body's own pain relieving system
 EPA Studies have shown that a diet rich in polyunsaturated fats and
low in saturated fat supplemented daily with 1.8 grams of
eicosapentaenoic acid (EPA) brought about significant improvement
in patients suffering from RA..
Flavonoids Several bioflavonoids are shown to possess beneficial
effects in individuals with RA. Some flavonoids inhibit the release of
histamine and the production of leukotrienes (a potent
inflammatory compound).
Glucosamine sulfate-not to the same extent as for osteoarthritis,
but also considered moderately effective in treating RA..
Glutathione peroxidase is important in reducing the production
of inflammatory prostaglandins and leukotrienes. Free radicals,
oxidants, prostaglandins and leukotrienes are known to cause much
of the damage to tissues seen in RA. So, we can infer that a
deficiency of selenium can adversely affect sufferers of RA. One
clinical study indicated that selenium combined with vitamin E had
a positive effect.. RA places and increased demand for selenium in
the body. Selenium also plays a synergistic role with other
antioxidant mechanisms
 Glutathione peroxidase is important in reducing the
production of inflammatory prostaglandins and
leukotrienes. Free radicals, oxidants, prostaglandins and
leukotrienes are known to cause much of the damage to
tissues seen in RA. So, we can infer that a deficiency of
selenium can adversely affect sufferers of RA. One clinical
study indicated that selenium combined with vitamin E
had a positive effect. We recommend supplementation of
selenium if you are suffering from or are prone to RA. RA
places and increased demand for selenium in the body.
Selenium also plays a synergistic role with other
antioxidant mechanisms.
Manganese Manganese functions in the antioxidant
enzyme superoxide dismutase which is deficient in
patients with RA. Manganese supplementation has been
shown to increase SOD activity. This, in turn, increases the
antioxidant activity. Take 30 mg daily.
 Niacinamide High doses (900 to 4,000 mg in divided
doses daily) of niamicide had been found to be very
effective in the treatment of rheumatoid and
osteoarthritis.
Caution: High doses of niacinamide may result in
significant side effects such as glucose intolerance and
liver damage.
Proteolytic enzymes Pancreatic enzyme preparations
and the protein digesting enzyme of the pineapple
(bromelain) have been demonstrated to be an effective
anti-inflammatory agent. They reduce swelling and help
the body eliminate the immune complexes that would
otherwise be deposited within the joints.
Selenium Serum selenium levels are low in patients with
RA. Selenium plays a valuable role as an antioxidant and
serves as the mineral cofactor in the free radical
scavenging enzyme glutathione peroxidase.
 Superoxide dismutase This antioxidant enzyme protects cells
and tissues from free radical damage. The injectable form of this
enzyme has been shown to be effective in the treatment of RA
and osteoarthritis. It is not clear whether an orally administered
SOD has any beneficial effect as it may not survive the digestion
in the intestinal tract.
Tryptophan Tryptophan is an amino acid that is found to be
deficient in individuals with RA. It is the precursor to the
neurotransmitter serotonin. Serotonin dampens our perception
of pain. Tryptophan also increases endorphin activity.
Tryptophan supplementation has been shown to reduce the level
of pain in patients suffering from acute as well as chronic pain.
Best results are obtained if you combine tryptophan
supplementation with a diet consisting of 80 per cent
carbohydrate, 10 per cent protein and 10 per cent fat.
Vitamin C Vitamin C is an important antioxidant. Vitamin C
increases SOD activity, decreases histamine levels and provides
anti-inflammatory action.
 Vitamin E Vitamin E is an important
antioxidant. It also works in combination with
glutathione peroxidase and other antioxidant
enzymes (superoxide dismutase, catalase). It
also has a slight anti-inflammatory action
due to its effect on prostaglandin and
leukotriene synthesis. Vitamin E combined
with selenium supplementation has been
shown to improve RA.
Zinc Zinc is an antioxidant. It also works
with the antioxidant enzyme superoxide
dismutase. Zinc levels are typically reduced
in patients with RA.
 Rangkuman
INTERVENSI GIZI PADA RA
Tujuan :
mencapai dan mempertahankan status gizi
optimal
menurunkan berat badan hingga mencapai
kondisi optimal, yaitu pada kasus yang
disertai obese
mengurangi nyeri sendi, yaitu dengan
mengurangi reaksi peradangan dan
progesinya
 Syarat Diet RA
Asupan protein harus cukup
Lemak dan karbohidrat harus dibatasi
Tinggi serat
Asupan Kalsium dan Vitamin D yang rendah
sering ditemukan pada penderita RA, maka
asupannya harus sesuai AKG
Asupan antioksidan ditingkatkan, yaitu dengan
meningkatkan asupan vitamin C, vitamin A dan
vitamin E
Mineral-mineral seperti seng, selenium, besi dan
magnesium harus cukup
 Jenis Diet :

RKRL (rendah kalori, rendah lemak),

yaitu untuk RA yang disertai obese
Tinggi kalori dengan protein cukup,
yaitu untuk RA yang mengalami gizi
kurang
 Anjuran Gizi :

Makanan yang seimbang antara asam dan

basa sangat bermakna untuk mengurangi
reaksi inflamasi. Pada artritis, makanan
yang membentuk basa akan membantu
untuk mengurangi reaksi peradangan.
Meningkatkan asupan anti oksidan yang
berperanan penting dalam mengurangi
reaksi peradangan dan meningkatkan
sistem kekebalan tubuh. Contoh antioksidan
antara lain vitamin C, vitamin E, dan
 Anjuran Gizi
Vitamin C ini pada penyakit arthritis
sangat penting untuk membantu
pembentukan tulang dan tulang
rawan, atau dengan kata lain
pembentukan jaringan sendi yang
sehat. Kolagen yang merupakan
bahan baku untuk tulang dan
kartilago membutuhkan vitamin C
untuk pembentukannya.
 Anjuran Gizi
Vitamin E
Vitamin E (alpha-tocopherol) mempunyai peranan yang
sangat penting bagi kesehatan secara keseluruhan .
Vitamin ini dapat meningkatkan suplai oksigen ke otot
dengan meningkatkan sirkulasi dan meningkatkan
kemampuan gerak otot. Vitamin E akan menstabilkan
membran dan melindunginya dari radikal bebas.
Vitamin A
Mengkonsumsi susu skim sebagai sumber kalsium yang
murah dibandingkan susu penuh.
Mencukupi kebutuhan akan mineral-mineral, seperti
seng, selenium, besi, dan magnesium.
 Anjuran Gizi
Seng
Seng ditemukan pada alpha-macroglobulin yang
merupakan protein yang penting pada sistem kekebalan
tubuh. Seng ini mempunyai peranan penting pada
pembelahan dan fungsi sel. Seng juga mempengaruhi
reaksi inflamasi di cairan sinovial pada arthritis.
Selenium
Selenium merupakan mineral kofaktor dari enzim
glutathione peroxide. Enzim ini berperanan penting
dalam mengurangi produksi prostaglandin yang
berperanan pada reaksi peradangan.

 Besi
Besi mempunyai peranan dalam membantu transport oksigen ke sel
dan besi ini dibutuhkan oleh enzim antioksidan superoxide dismutase
agar dapat berfungsi. Sehingga berperanan penting dalam reaksi
inflamasi. Seperti Seng, pada saat inflamasi di persendian
konsentrasinya cukup tinggi yang mengindikasikan peningkatan
aktivitasnya melawan kerusakan sendi.
Magnesium
Magnesium berperanan agar fungsi kalsium maksimal, terutama untuk
absorbsi.
Meningkatkan asupan minyak ikan yang mengandung eicosapentaeonic acid
( EPA ) dan docosahexaenoic acid ( DHA ). Kedua substansi ini dapat berubah
menjadi anti peradangan sehingga dapat membantu mengurangi nyeri dan
kekakuan pada sendi. Minyak ikan ini juga banyak mengandung vitamin A dan
D. Kedua vitamin ini berperanan penting bagi kesehatan kulit, tulang dan gigi.
Dosis suplemen minyak ikan adalah 3 4 g per hari.