Medical Nutrition Therapy for

Diseases of the Musculoskeletal and

Nervous System
 Introduction
• This topic has combined two important bodily
systems: physical and mental
• A review of the anatomy and physiology of
muscles, bones, and nerves reveals how closely
related these structures are.
• A decline in cognitive functioning is one of the
strongest predictors of impending mortality
• Cognitive decline can occur with marked variation
among individuals and nutrition is one factor that
is believes to be influential
 Factors Affecting the Potential Role of Diet
According to Benton (2010)
• First, cognitive or brain reserve is said to decrease the
incidence of dementia; i.e. it has been suggested that
those with larger brains and better intellectual functioning
have a greater capacity to resist the effects of the
biological changes that define dementia

• Second, shrinkage of the brain begins in young adulthood,

suggesting that any insidious influence of diet will take
place from that time onward. The marked decline in the
weight of the brain associated with advanced dementia
suggest it will be easier to slow that decline than repairing
the brain
• Therefore, diet is influential throughout the
entire lifespan and that it affects
neurodevelepment, neurodecline, cognitive
performance, and that nutritional adequacy
plays a crucial part in limiting the
development of dementias
 THE MUSCULOSKELETAL SYSTEM
• The musculoskeletal system includes the bones,
muscles, and joints.

• The muscles are responsible for movement of

the body and classified as cardiac (heart
muscle), skeletal (striated muscle), and smooth
(non-striated muscles of the gastrointestinal
tract, blood vessels, and other involuntary
muscles)
• The skeletal system forms the supporting
framework of the body. It consists of axial (skull,
vertebral column, ribs, and sternum) and
Appendicular (extremities)
• The tendons that aid in locomotion attach the
muscles to the skeleton

Disorders of the Musculoskeletal System

• Musculoskeletal diseases are those that affect
the bones, joints, and muscles; some also affect
the internal organs and skin
 Rheumatic Diseases
• Mostly affects the joint tissues and cause
symptoms of arthritis
• The basic structures affected by these
diseases are the connective tissues
• Connective tissues are found in every organ
so manifestations of the disease may vary
• The diseases are often accompanied by pain,
inflammation, and sometimes are disabling
 *arthritis warning signs
• Persistent pain and stiffness on arising
• Pain, tenderness, and swelling in one or more
joints
• Recurrence of these symptoms especially
when they involve more than one joint
• Recurrent or persistent pain and stiffness in
the neck, lower back, knees, and other joints.
 Osteoarthritis
• Also known as degenerative or hypertrophic
arthritis, is the most common form of all joint
disorders.
• A type of arthritis caused by inflammation,
breakdown, and eventual loss of cartilage in the
joints; it can also be caused by aging, heredity,
and injury from trauma or disease
• Often observable in elderly and in obese
persons
Nutrition Therapy
• Diet has a little role in the treatment unless the
patient is obese, in which case a low calorie
diet is necessary in order to reduce the strain
on the weight-bearing joints or maintain weight
• For non-obese, a diet adequate in protein,
vitamins, minerals, and fluids is sufficient.
• In both cases, increased use of fish or fish oil
(not supplements) is recommended for
reducing inflammation. Adequate intake of zinc
and vitamin C and E are needed.
 Gout
• Disorder of purine metabolism characterized by
elevated uric acid levels in the blood. Resulting
in deposition of urate crystals in the body
• It is also characterized by severe pain in the
joints following an exceptionally large amount of
stress.
• Sometimes, the affected joints swell and
become red and tender. People with gout have
the tendency to develop kidney stones
• The risk factors are obesity, high alcohol intake,
high serum levels of uric acids (which may be
hereditary), use of some hypertension drugs, and
high intake of purines.
• Attacks often can be triggered by:
Drinking alcohol especially during a binge
Over-eating especially if on a high purine diet
Minor injury to a joint
Drinking insufficient fluids
Fluid depletion due to certain drugs such as diuretics
Attempting a “crash diet”
Fasting, e.g. before surgery
Nutrition Therapy
• If the patient is obese, a reduction in weight is
necessary. Fluids should be plentiful to
eliminate urates
• A high carbohydrate and low fat diet also
supports proper elimination of urates.
• Urate crystals are usually formed with high
sodium load; therefore reduce the intake of salt,
and condiments (patis, toyo, bagoong, etc.)
Rheumatoid Arthritis (RA)
• An autoimmune disease that causes chronic
inflammation of the joints, tissues around the
joints, and other organs in the body.
• Referred as a systematic illness and is
sometimes called rheumatoid disease because it
can affect multiple organs
• Less common than osteoarthritis but it is more
severe and the cause is unknown.
• Patients are usually underweight and occurs
much more in women than in men
Inflammatory process
• The inflammation (called synovitis) results in
the warmth, redness, swelling, and pain.
These are common symptoms of RA.
• First, the cells of the synovium grow and divide
abnormally, making the normally thin synovium
thick - resulting a joint to swell and puff.
• As RA progresses, these abnormal synovial
cells begin to invade and destroy the cartilage
and bone within the joint.
• The surrounding muscles, ligaments, and
tendons that support and stabilize the joint
become weak and unable to work normally.

• All of these effects lead to the pain and

deformities often seen in RA
• RA patients’ nutritional status is affected through
several ways; the inflammation leads to increased
nutritional requirements because of the increase in
metabolism
• Gastritis is often present due to the side effect of
medication
• The crippling nature of the disease may affect the
individual’s food intake
• The side effects of medications should be
considered and weight changes monitored.
• The goal of treatment in RA is to reduce joint
inflammation and pain, maximize joint function,
and prevent joint destruction and deformity.
• The major approach is to control symptoms and prevent
further disability through a combination of a program of
medical, surgical, rehabilitative, and dietary services.

• The objectives of management are the following:

Control pain and inflammation in the joints and other tissues
using anti-inflammatory drugs and nonsteroidal anti-
inflammatory.
Maintenance of joint function and prevention of deformities
through therapeutic exercises designed to preserve joint
motion, muscular strength, and endurance.
Repair of joints damage through surgical intervention. This
involves replacing irreversibly damaged joints, improving
functional capacity, or preventing damage to normal joints
 Nutrition Therapy
• To date, there is no specific diet that cures
arthritis.
• Calories should be adequate to meet the needs
of the patient for daily activities
• If patient is obese, a weight control diet is
desirable. Patient should be at the level of the
recommended dietary allowance.
• If patient is in a poor nutritional status or who is
in the inflammatory stage, 1.5 to 2kg of protein a
day is advised
• The intake of fish oils has been proven to help
with the inflammation
• Recent reports suggested that a Mediterranean
or vegetarian diet and/or eating Bing cherries
helped some cases of RA
• Low levels of Vitamin B6 and Vitamin C have
been seen in patients with RA,
• and patients with RA usually have lower zinc
levels than normal individuals
 Juvenile Rheumatoid Arthritis (JRA)
• Or Still’s Disease is an autoimmune disorder that
usually occurs in children under 15 years old
• In addition to the symptoms of arthritis;
splenomegaly, lymphadenopathy, leucocytosis,
pyrexia, rash, and involvement of the cervical spine
occurs.
• As the child matures, their condition merges into a
form similar to that of adults.
• Most children with JRA need medication and
physical therapy
Nutrition Therapy
• There are no data suggesting specific food that
causes or alleviate JRA
• Nutritional care can be important in related
problems such as malnutrition, growth
retardation, weight loss, obesity, and nutrional
anemia.
• Treatments can help to preserve a high level of
physical and social functioning maintaining a
good quality of life.
Systemic Lupus Erythematosus (SLE)
• An autoimmune disease in which the immune
complexes of DNA and anti-DNA produce a
vasculitis causing lesions in many parts of the
body, particularly the joints, skin, kidney,
spleen, pleura, pericardium, endocardium, and
nervous system.
• In some cases, a viral infection may produce
the immune changes.
• The most common symptoms are extreme
fatigue, fever, an acute migratory arthalgia
resembling rheumatic fever and cold, and
numb fingers.
• There may be skin ulceration because of
abnormal sensitivity to sunlight.
• To date, there are five survivors of SLE in the
Philippines.
Nutrition Therapy
• Potassium supplement is needed if increased
potassium needs are not met through dietary
means.
• High calorie, high protein soft diet is
recommended during fever. Diet is further
altered when there is kidney damage.
• Some evidences show that a diet low in
saturated fat and supplemented by fish oil may
be helpful.
Duchenne Muscular Dystrophy (DMD)
• DMD is the most common form of muscular
dystrophy causing muscle deterioration and an
eventual death in men usually before age 30.
• It is a hereditary disease. The gene responsible
for the production of a key muscle protein
called dystrophin is defective.
• The lack of which is associated with complete
muscle corrosion over the first two decades of
life.
• Levels of creatine phoshokinase (CPK), an enzyme
involved in the production of energy for muscle
contraction are markedly elevated in the blood.

• Damage to muscle fibers in DMD has already begun

even before birth. However, visible signs of
weakness are usually evident at 2-3 years old when
the child begins to stand and walk.

• By the age of 4-5, the child is no longer able to keep

up with peers.
• Respiratory failure is the major life-threatening
manifestation of the disease.

• Patients with trouble in swallowing (dysphagia)

are at high risk of compromised nutritional status.

• Other neuromuscular disorders can also cause

nutritional problems.

• Weight gain is evident and nutritional problems in

patients with DMD.
Nutrition Therapy
• An accurate diagnosis of the neuromuscular
disorder is essential in order to determine how
best to achieve adequate nutrition.
• Dietary management depends on the nature
and scope of the swallowing problem.
 Osteopenia and Osteoporosis
• Osteopenia - condition of the bone mass density
(BMD) less than normal and has no symptoms. The
BMD is not low enough to be identified as
osteoporosis.
• Osteoporosis - multifactorial condition influenced
by a number of genetic, dietary, and lifestyle
factors.
- progressive decrease in the density of bones,
which makes them brittle
Osteoporosis
• One in four women may develop osteoporosis
• Primarily related to the aging process (older women
are at higher risk)
• Type 1 Osteoporosis – occurs in women after 5-20
years of menopause. Pain in the vertebrae, rounding
of shoulders, height loss, and susceptibility to
fractures are experienced.
• Type 2 – observed in individuals older than 85 years
and develops slowly than Type 1
• Type 1 responds to estrogen therapy while Type 2
may respond to calcium increases
• Can progress without symptoms and it may not be
years until later fracture takes place.
• Most common symptoms are bone fractures in the
spine, hip, or wrist.
• One sign of vertebral fracture is height loss, which
may lead to “Dowager’s Hump” (the disfiguration
of the back that results in stooped posture)
• Most frequent fracture is the hips. It can lead to
chronic pain, disability, and disfigurement. if not
controlled, may lead to death
Risk Factors for Osteoporosis
• Gender (women are at greater risk) • History of fractures among elderly
relatives
• Early menopause (before 45 y/o) • Abnormal absence of menstrual period

• Surgical menopause (removal of • Anorexia nervosa or Bulimia

ovaries)
• Low bone mass • Low testosterone levels in men

• Family history of osteoporosis • Lactose intolerance

• Poor nutrition (low calcium and Vit. D) • Certain medications (e.g. , excessive
amounts of thyroid medication)
• Lack of weight-bearing exercise • Illnesses that impair absorption of
calcium
• Cigarette smoking

• Excessive alcohol consumption

• In osteoporosis, the goals of management are:
Stop or reverse bone loss
Increase or stabilize bone mass, and
Reduce fractures, pain, disability, and mortality.
• Estrogen, calcitonin, and biphosphonates are
medications usually prescribed.
• Building the bones before the age of 35 can be
best defense against developing osteoporosis.
Nutrition Therapy
• Diet alone has not been proven to treat
osteoporosis when it has already developed.
• For preventive purposes, a diet with a calcium of
1000 to 1200 mg during the growing years is
advised.
• Calcium supplements are used as substitutes if
dairy products and other sources are not
tolerated or adequately taken
• For elderly women, physical activity is beneficial.
 THE NERVOUS SYSTEM
• The nervous system along with the endocrine
system correlates our adjustments and
reactions to internal and external conditions
• Has 4 main parts – cranial, central (brain and
spinal cord), peripheral (peripheral nerves), and
autonomic
 Malnutrition Induced Neurologic Disorders

• These disorders are usually seen because of

chronic alcoholism, weakening disease that
affect the gastrointestinal tract, starvation,
malnutrition caused by diet ignorance, and
conditions caused by stress.
 Nutritional Neuropathy
• Most common form of nutritional disorder of the
peripheral nervous system.
• Treatment involves improvement on the overall diet

STAGES
• Early stages
Symmetric impairment of motor and sensory function
Reduced or absent reflex activity affecting the legs
• Late stages
Motor impairment
Complete paralysis may be elicited
 Vitamin B12 Neuropathy
• Described as a progressive degeneration of posterior
and lateral columns of the spinal cord due to a
deficiency in Vitamin B12

• Peripheral neuropathy, coldness, numbness, loss of

normal reflexes, weakness of extremities, and mental
deterioration are observed

• Treatment is achieved by administration of diet used

for pernicious anemia but with increased doses of
cyanocobalamin
Pyridoxine (Vitamin B6 deficiency) Neuropathy
• Results from anti-tuberculosis drug (isoniazid) in
adults and dietary deficiency in infants
• It may lead to brain damage and mental retardation
in infants. In adults, mood changes, excessive
somnolence, and even psychosis.
• Women using oral contraceptives may also
experience the same symptoms because it may also
lead to Vit. B6 deficiency
• Treatment is through intake of large amounts of
pyridoxine
Vitamin E deficiency
• Symptoms are motor-sensory polyneuropathy,
trunkal and limb ataxia, opthalmoplegia, retinal
degeneration, and myopathy.
• In severe cases, it may result in neuroaxonal
degeneration and destruction of muscle fibres
• Treatment is follow Vitamin E therapy
Pellagra (Niacin Deficiency)
• In the early stages, the patient may be depressed,
apathetic, fearful, and apprehensive.
• Insomnia, dizziness, and headache are common.
• As the disease progresses, psychosis
characterized by confusion, disorientation, and
hallucinations may develop
• Later, the patient may lapse into coma.
• Large amounts of niacin about 10-20 mg per day
in the presence of adequate tryptophan is needed.
 Wernicke-Korsakoff Syndrome
• Deficiency of thiamin which causes cardiovascular,
central, and peripheral nervous system disturbances.
• Results from inadequate dietary intake or from
impaired absorption of Vitamin B1
• Symptoms may be vomiting, diplopia, and
nystagmus. Followed by mental changes, apathy,
emotional disturbances, loss of memory,
disorientation, and hallucination
• Death is common if untreated. If patient survives, the
cerebral cortex may be damaged
• This condition occurs primarily in alcoholics
 Anticonvulsant-Induced Vitamin Insufficiency

• Nutritional deficiencies may also arise as a result

of using anticonvulsants usually used for seizure
and medications.
 DIETARY EXCESSES
• Food Additives - artificial coloring, sugar, flavor, preservative
are responsible for certain learning and behavior problems
associated with attention deficit disorder with or without
hyperactivity
- The red dye (FDC #3) and yellow dye (yellow No.5) are the ones
usually implicated which led to the banning of these two colors in
many food products
• Alcohol and Other Drugs – alcohol has been used clinically as
a appetite stimulant, as a sedative-hypnotic drug, and as a
calorie source.
- Alcohol is absorbed as a drug and as a macronutriet
- In high dosages, it has direct toxic effects on the nervous system
and on other body systems
- Damages the liver, which can interfere with Vitamin D
metabolism

- Alcohol can impair behavior, judgment, memory,

concentration, and coordination.

- In pregnant women, alcohol abuse can lead to Fetal

Alcohol Syndrome (baby suffers from birth defects and
mental retardation)

- Alcoholics often present symptoms of gastritis, peptic

ulcer, acute alcoholic hepatitis leading to cirrhosis and
bronchitis
- Alcohol is a drug that burns rapidly in the body. It
produces 7 calories per gram

- If alcohol is taken in excess of 50% of total

calories, it causes the displacement of nutrients
because of malabsorption and increased excretion

- Absorption of alcohol is delayed if taken with a

meal
• Caffeine – is a central nervous system stimulant
belonging to a group called methylxanthines
- Excessive caffeine intake can lead to jitterness,
agitation, and insomnia
- When individuals addicted to caffeine withdraw from
it, symptoms (headache, drowsiness, irritability, and
mild depression) begin within 18 to 24 hours.
- Low doses (<50 mg/d) have little effect on
gastrointestinal function.
- Intakes of 200-300 mg/d are still considered safe for
most adults
- At higher levels (>300 mg) addiction and symptoms
may occur
- Pregnant women are recommended to reduce
caffeine intake during early pregnancy
- Caffeine is not considered an important risk factor
for osteoporosis

 Nutrient Excesses
Vitamin A – rise in intracranial pressure leading to
drowsiness, irritability, headache, vomiting, and peeling of
the skin
Vitamin D – usually seen in infants, manifestation of
hypercalcemia is evident. In addition, there’s mental
retardation, weakness, fatigue, lassitude, and headache.
Vitamin B6 – in large doses, has been shown to cause
sensory neuropathy
Lead – is never a normal part of the body
- It is widely distributed in our environment (air,
dust and soil, food, and waiter) and has many
uses
- Small amounts of lead in the body have no bad
health effects
- Lead toxicity may cause anemia, kidney damage,
decrease in bacterial and infection resistance, and
nervous system damage in children
Nutrition Therapy
• Evidence shows that diet deficient in calcium,
zinc, iron, and copper and associated with
increased absorption of lead in the
gastrointestinal tract
• Fluid intake must be adequate
• Vitamin and mineral supplements are also
considered
Developmental Disabilities with Neurological Disorders

• Refer to significant physical, mental, or sensory

impairment often accompanied by associated
disabilities found in various combinations

• Some of these conditions are cerebral palsy,

Down’s syndrome, and fetal alcohol syndrome
 Cerebral Palsy (CP)
• A type of brain damage resulting from birth injury,
cerebral hemorrhage, prematurity
• It is characterized by two motor disability: atheosis
and spinal paralysis
• Atheosis – movement is uncontrollable, the child
needs an increased intake of calories but because of
neuromuscular control may find difficulty in feeding
himself.
• Mixed Cerebral Palsy – condition when both
spasticity and atheosis may be present
• Spastics – limited activity prone to obesity
Nutrition Therapy
• Swallowing difficulty should be assessed by a
speech pathologist to determine the current stage of
dysphagia
• Some may combing oral and tube feeding to supply
all the fluid, calorie, and nutrient requirements
according to age and gender
• For spastic patient, calorie intake must be controlled
to prevent too much weight gain
• Maintenance of good nutritional status and helping
the child to lead a normal life
• Finger foods are enjoyed by some individuals
 Down’s Syndrome (Mongolism)
• This condition is caused by trisomy of chromosome
21, directly correlated with the age of the mother
(above 41 yrs. old of conception)
• Children suffering from this are usually short and
overweight, with signs of mental retardation that
varies from mild to sever
• Patients are characterized by growth retardation,
protruding tongue, delayed development of oral
reflexes, poor swallowing, and chewing difficulties