Nutritional Aspects of Juvenile Idiopathic Arthritis: An A to Z for Dietitians

Abstract

Juvenile idiopathic arthritis (JIA) represents a chronic, autoimmune, rheumatic musculoskeletal disease with a diagnosis before 16 years of age. Chronic arthritis is a common manifestation in all JIA subtypes. The nature of JIA, in combination to its therapy often results in the development of nutrition-, gastrointestinal (GI)- or metabolic-related issues. The most-common therapy-related nutritional issues involve methotrexate (MTX) and glucocorticosteroids (GCC) adverse events. MTX is a folic acid antagonist, thus supplementation with folic acid in required for improving GI side effects and correcting low serum levels. On the other hand, long-term GCC administration is often associated with hyperglycemia, insulin resistance and growth delay. This relationship is further aggravated when more joints are affected and greater doses of GCC are being administered. Apart from stature, body mass index z-scores are also suboptimal in JIA. Other signs of malnutrition include decreased phase angle and muscle mass, especially among patients with polyarthritis JIA. Evidence also points to the existence of an inverse relationship between disease activity and overweight/obesity. Specific dietary patterns, including the anti-inflammatory diet, might confer improvements in selected JIA outcomes, but the level of available research is yet insufficient to draw safe conclusions. The majority of patients exhibit suboptimal vitamin D status; hence, supplementation is recommended. Collectively, the evidence indicates that, due to the age of onset and the complexity of the disease, along with its pharmacotherapy, children with JIA are prone to the development of several nutritional problems, warranting expert monitoring. Vitamin deficiencies, oral and GI-problems limiting dietary intake, faltering growth, overweight and obesity, physical inactivity, or impaired bone health are among the many nutritional issues in JIA requiring dietitian support.

Anorexia nervosa and systemic lupus erythematosus: a coincidence?

“…The severity of the AN symptoms and the progression of behavioral or psychotic disorders contribute to delayed diagnosis 2 . The onset of AN occurs in adolescence, and recently, an increase in adolescent incidence happened 13 . Our patient is 22 years old.…”

“…Our patient had no adverse effects of steroids. Steroid-induced changes in body weight and shape might act as triggers for the development of body dissatisfaction and AN 13 . Our patient was not treated with steroids when AN began.…”

“…The coexistence of AN and SLE is reported in rare cases 2,13 . Juvenile SLE and AN were reported in three cases and one case series 2,19–21 ; meanwhile, Sloan et al 21 .…”

“…Clinical features common for AN and SLE are weight loss, malaise, uncommon fatigue, and cognitive and mood disorders 2 . SLE itself, may be presented by anorexia and nausea, which will make it difficult to differentiate the symptoms of AN from those of lupus 13 . There is increasing evidence that AN is among the neuropsychiatric manifestations of lupus.…”

“…AN has been associated with the stress of chronic disease diagnosis; on the other hand, the chronic inflammation associated with AN may contribute to the development/appearance of SLE. Adverse childhood experiences, concentrations of leptin, shared autoantibodies, and genetic traits appear to be important factors in this well-established interplay 23 .…”