CPE Monthly: MNT for Inflammatory Rheumatic Diseases
By Tony Pipkin, MS, RDN
Today’s Dietitian
Vol. 25 No. 6 P. 42

CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Rheumatic disease, an all-encompassing term, represents more than 150 medical conditions, each with a unique pathogenesis, prognosis, clinical course, and therapeutic protocol.1 The diseases have a long history, dating at least as far back as Ramses II, one of the ancient Egyptian Pharaohs whose 3,000-year-old mummy had skeletal changes indicative of ankylosing spondylitis. The Egyptians coined the term “podagra” (gout) in 2640 BC.2 The musculoskeletal system is the primary target tissue for the autoimmune antibodies in rheumatic diseases resulting in significant joint pain (arthralgia) and limited flexibility. Secondarily, inflammation affects cardiovascular, epidermal, pulmonary, ocular, and renal systems with resultant pain, tissue destruction, disabilities, concomitant diseases, and increased mortality.3-6

Rheumatic diseases can be subdivided into inflammatory rheumatic diseases (IRDs) and noninflammatory rheumatic diseases, the latter being more age dependent with a markedly better prognosis.7 IRDs encompass more than 30 distinct disorders, including rheumatoid arthritis (RA), gout, scleroderma (systemic sclerosis), Sjögren’s syndrome (SS), systemic lupus erythematosus (SLE), and spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, acute anterior uveitis, and reactive arthritis), among others.8-10 IRDs affect multiple body systems, so anti-inflammatory nutrition often is beneficial, as well as recommendations for diet that support a healthy microbiome. Multiple studies have addressed RA and the Mediterranean diet, as well as the role of omega-3 polyunsaturated fatty acids (PUFAs) in reducing inflammation. While many of the answers are inconclusive, several opportunities exist for the role of nutrition in the management of IRDs.

This continuing education course reviews nutrition interventions for common IRDs. Pharmacological and physical/occupational therapies also are addressed. Finally, counseling strategies for clinicians are provided.

Prevalence of Common IRDs
IRDs are thought to be expressed as interactions between genetic coding, autoimmunity, and environmental influences such as cigarette smoke, pollution, or infections. Over 50 million Americans suffer from musculoskeletal diseases, with rheumatic diseases affecting approximately 7 million.3 Rheumatic diseases afflict women at a rate of 8.4%, and men at 5.1%, typically between the ages of 15 and 50.11 RA is one of the most common IRDs affecting 1.3 million adults, and more than 1.4 million patients (typically 15 to 44 years old) suffer from SLE. Surprisingly, spondyloarthropathies are more common than RA, affecting 3.2 million adults.12,13

Data from the CDC and the Lupus Foundation of America have determined that many rheumatic diseases develop disproportionately in People of Color (POC). Asian American and Latina women are almost twice as likely to develop SLE compared with their white female counterparts, and SLE affects renal, hematological, and other organs with greater frequency. The origin of SLE, like other IRDs, remains unknown, although genetics, hormones, and environment are suspected components.14-16 Many of the IRDs preferentially strike women for reasons unknown. RA occurs two to three times more frequently in women than men, although men typically have a more serious disease, and 90% of newly diagnosed lupus cases are women between the ages of 15 and 45. Women are afflicted with SS more than men by a 9:1 ratio, and it’s thought to be attributable to genetics, environmental influence, and postmenopause hormonal changes.13,17-19

A 2022 study by McCormick and colleagues addressed racial and gender variations in gout in the United States. More than 18,000 men and women with gout identified as either Black or white in the cross-sectional study. Gout frequency was 1.8 times and 1.3 times more in Black women and Black men, respectively, compared with their white counterparts. Contributing factors of poverty, BMI, chronic kidney disease, and diet were associated with the increased incidence.20

Using data from the National Health and Nutrition Examination Survey study (2007–2008), Zhu and colleagues evaluated the prevalence of gout and hyperuricemia in US adults, determining that the incidence has increased over the last 20 years to 8.2 million adults. The authors allude to increases in obesity and hypertension as causative factors.21-23 Scleroderma is considered a rare disease affecting 75,000 to 100,000 people in the United States, predominately women, and Black women are adversely affected with far greater pulmonary damage than white women.4,24,25 Approximately 300,000 children (one in every 250) in the United States live with rheumatic disease, juvenile idiopathic arthritis being the most prevalent.3 Comparatively, 5% of the US population lives with a chronic IRD, and the disability rate is higher than that of cancer, diabetes, or heart disease.7

Overview of Common IRDs

Rheumatoid Arthritis
The genetic component of RA is theorized to be hereditary with contributing factors such as smoking and obesity. In RA, the immune system attacks the synovium, a specialized connective soft-tissue membrane lining synovial joint capsules.26 The inflammatory response includes a thickened proliferation of synovial cells. Over time, severe cartilage damage ensues followed by joint deformity and functional loss. RA is divided into seropositive and seronegative, and a third classification of juvenile RA, better known as a juvenile idiopathic arthritis, typically occurs before age 16.27 A 2018 Italian study by Salaffi and colleagues evaluated the impact of 14 multiple rheumatic diseases on the health-related quality of life including the IRDs ankylosing spondylitis, RA, and psoriatic arthritis. Of the IRDs studied, RA had the greatest negative consequence of all 14 conditions.28 Interstitial lung disease is a common, and life-threatening comorbid condition in RA with pulmonary fibrosis restricting pulmonary exchange.29 Diet and nutrition have a significant role in etiology and in RA management.

Arthritis of the spine secondary to long-term inflammation, typically affecting the sacroiliac joint, is known as ankylosing spondylitis or Bechterew’s disease. Causes are unknown, although genetics and environmental conditions such as bacterial infections are thought to be contributory. Ankylosing spondylitis was believed to affect men twice as much as women, but a 2018 review determined that prevalence was almost equal, with women suffering more due to delayed diagnosis, more severe disease, and decreased treatment response.30 Approximately 20% of patients with inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease develop enteropathic arthritis, which is associated with gut dysbiosis, and is hypothesized to be the bacterial source prompting the inflammatory response. Other gastrointestinal diseases (eg, celiac, Whipple) also are associated with enteropathic arthritis.31,32

Most patients with spondyloarthropathies have a gene that produces a human leukocyte antigen (HLA-B27) that, in combination with a trigger, such as bacteria, initiates an inflammatory response.33 Diets’ influence in the gut microbiota have long been recognized but only recently have the roles of HLA-B27 and gut microbes undergone extensive analysis. Gill and colleagues assessed pathobionts associated with spondyloarthropathy looking at the role of prebiotics/probiotics, diet, and fecal transplants. The presence of a healthy and diverse gut flora, rich in short-chain fatty acids and fiber, is considered to be protective. The typical Western diet is high fat, low fiber, and associated with multiple inflammatory diseases. Current trials are underway with fecal transplantation for RA and psoriatic arthritis.34

Psoriasis, another IRD, produces scaly dermal patches on the knees, elbows, and scalp. Approximately 30% of these patients develop psoriatic arthritis, typically affecting fingers, wrists, and knees. A further subset (20%) of patients progress to psoriatic spondylitis, which can result in spinal fusion. Like other IRDs, the cause of psoriatic arthritis remains unknown.35

SLE is the most common and dangerous version of lupus. Other types include cutaneous lupus, drug-induced lupus, and neonatal lupus (due to transplacental passage of maternal SLE antibodies), which has a 20% mortality rate.36,37 SLE can be a multiorgan inflammatory disease impacting renal, cardiopulmonary, neurological, dermal, and musculoskeletal systems. There’s no cure, but therapeutic management often can yield a quality, and functional life. Symptoms, which often flare up and then recede, may include oral ulcers, skin rashes, fatigue, chest pain, fever, musculoskeletal inflammation, and pain. The risk of CVD (hardened arteries, congestive heart failure) due to the chronic inflammation also is increased.38

Causes of SLE, like many other IRDs, have genetic, environmental, and hormonal components. Schneider and colleagues in 2014 completed a literature review that led to the recognition that patients with SLE frequently have low serum vitamin D levels and recommended vitamin D supplementation. Multiple international studies found that vitamin D deficiency is more common in SLE than in healthy individuals, but it wasn’t associated with SLE risk development. While vitamin D deficiency is more prevalent in SLE than in the general population and associated with clinical features of SLE, there’s no consensus on supplementation levels to ameliorate symptoms; however, the authors recommend supplementation to achieve normal serum values.39

Sjögren’s Syndrome
SS affects the exocrine glands, which secrete fluids, including enzymes, into or on the surface of surrounding tissue, such as skin, the gastrointestinal tract and epithelium lining the lungs. Destruction of the glands in this autoimmune disease results in oral, nasal, vaginal, ocular, and skin dryness.40,41

Delineation of SS into primary and secondary classifications is based on the extent of involvement of other target tissues. Primary SS produces dry eyes and oral mucosa and is occasionally referred to as “sicca syndrome.” Secondary SS is based on involvement of other autoimmune diseases, including primary biliary cirrhosis, RA, SLE, polymyositis, scleroderma, and mixed connective tissue disorder.42 Dietary changes can improve symptomatology and quality of life.

Scleroderma (Systemic Sclerosis)
This group of rare diseases has a five- to eight-fold increased mortality risk.3 Localized scleroderma, also known as morphea, affects only the skin. The more severe form of scleroderma, systemic sclerosis, may damage multiple organ systems (cardiovascular, gastrointestinal, pulmonary, and renal). Microvascular changes related to chronic inflammation and significant collagen deposits result in extensive tissue scarring. In addition to dermal manifestations, patients may experience Raynaud’s phenomenon and digestive issues such as indigestion, diarrhea, constipation, fecal incontinence, and dysphagia. Malabsorption due to intestinal bacterial overgrowth also has been documented.25,43 It’s not uncommon for patients with scleroderma to also suffer from RA, SLE, or SS.25

This form of inflammatory arthritis afflicts 4% of US adults and is attributable to increased serum uric acid. Gout may progress through four stages from asymptomatic hyperuricemia without needle shaped crystal deposition to crystal deposition without gout symptoms, to gouty episodes with crystal deposits, and finally advanced gout, including tophi development, which may take up to 10 years to develop.44 Risk factors for the development of gout, according to the National Institutes of Health, include genetics, consumption of alcohol, high fructose corn syrup, increasing age, hypertension, chronic kidney disease, sleep apnea, lead exposure, and obesity.45

Nutrition Management, Treatment of Common IRDs

General Nutrition Principles
The role of nutrition in the causation, development, and treatment of IRDs remains a challenge for clinicians and patients. Individuals with IRDs often have concomitant CVDs, osteoporosis secondary to chronic inflammation, and medication side effects.46 Emerging data suggest that macro- and micronutrients impacting the gut microbiome may have a beneficial influence on gut-immune communication pathways. Diagnostic and interventional nutrition therapies are desirable, but studies providing high grade recommendations are lacking.47

The absence of consistent guidelines for nutrition in IRDs led the French Society for Rheumatology to publish recommendations for RA, ankylosing spondylitis, and psoriatic arthritis based on a systematic literature review and clinical experience. The panel included 12 rheumatologists, a physician nutrition specialist, an internal medicine specialist, an RD, and three spokespersons from advocacy groups. The 2022 recommendations include eight general principles and nine recommendations. The principles emphasize the need for nutrition to be integrated into the overall care plan with pharmaceuticals and exercise.48 The recommendations address body weight, supplementation with omega-3 PUFAs, and inclusion of foods typically consumed within a Mediterranean diet. No supporting recommendations could be made for exclusion diets (ie, gluten-free in the absence of celiac disease, vegan, dairy-free, or fasting regimens) regardless of testimonials and marketing.

The lack of controlled clinical trials and adequate sample size make any exclusion diet recommendation unsupportable. In addition, data supporting dietary supplementation with probiotics, vitamins, and minerals are insufficient. Some spices like garlic, ginger, saffron, and cinnamon may have beneficial effects on inflammation, but the data are too sparse to make a recommendation for use in clinical settings.48 The strongest recommendation of the French Society for Rheumatology was for the Mediterranean diet (for RA), and supplementation with omega-3 PUFAs for patients with chronic IRDs, which was based on 43 randomized placebo-controlled trials, and multiple meta-analysis studies for IRDs, resulting in a grade A recommendation.48,49

Nutrition Counseling for RA
The lack of definitive dietary treatment for RA requires that issues found during nutrition assessments, food-drug interactions, and comorbid conditions and diseases should be addressed. Patients with RA often try dietary manipulation such as exclusion, vegan, and gluten-free diets, and will benefit from guidance about which nutrition intervention has validity.50 Considering the role of inflammation in RA, modification of dietary components by increasing antioxidants and decreasing proinflammatory foods is hypothesized to reduce symptoms. Foods such as those contained in the Mediterranean diet, rich in omega-3 PUFAs and fiber, yield some improvement in the clinical manifestations of RA.

In 2021, a study of 28 patients with long-term RA receiving disease-modifying antirheumatic drugs (DMARDs) participated in a three-month study excluding meat, gluten, lactose, and all dairy products (privative diet). Significant improvement in the levels of C-reactive protein, visual analogue scale (pain), disease activity score of 28 joints (DAS28), as well as the 36-item short-form health survey and health assessment questionnaire were reported in the research arm, leading the authors to conclude that the privative diet may be beneficial for people with stable long-term RA.51 The 2021 European Alliance of Associations for Rheumatology (EULAR) recommendations for nutrition intervention in RA looked at studies researching animal products, experimental diets, plant-based diets, and vitamins/minerals/supplements. From the many random controlled trials and meta-analyses reviewed, the authors concluded that marginal quality evidence supported omega-3 PUFAs, probiotics, and vitamin D. Other diet manipulations were graded as low or very low.52,53

A recent randomized crossover study of 32 patients with RA evaluated a low-fat vegan diet with the removal of trigger foods (eg, gluten, nuts, citrus, chocolate). The trial consisted of a four-week vegan diet, followed by removal of trigger foods for three more weeks, and then reintroduction of suspected problem foods over another nine-week period. After a four-week washout trial, subjects reverted to a 16-week trial with a placebo supplement. The participants in the diet phase experienced a decrease in DAS28 scores and BMI. The authors postulate that a vegan diet with the elimination of trigger foods resulted in decreased symptoms and severity of RA.54

Methotrexate is an effective drug used in the medical management of RA. It’s success as an anticancer drug was based on its ability to block folate metabolism. Consequently, patients taking methotrexate should eat folate-rich foods such as asparagus, Brussels sprouts, black beans, broccoli, eggs, edamame, bananas, whole grains, peanuts, and beans with a goal of 1 to 3 mg of folate daily, which may require supplementation with folic acid.55

Nutrition Counseling for Spondyloarthropathies
Many patients seek recommendations to improve their spondylitis arthritis through diet. It’s not uncommon for patients to try exclusion diets or nutritional supplements to minimize the impact of spondylitis. They’re at greater risk of osteoporosis, and adequate vitamin D and calcium intake are important. Moreover, alcohol consumption increases the risk of bone fracture. Due to the increased incidence of enteropathic arthritis in patients with celiac disease, it’s appropriate during counseling to address the gluten-free diet. While patients with ulcerative colitis may suffer enteropathic arthritis less, nutrition advice for this disease is essential.56

Nutrition Counseling for SLE
The 2021 EULAR recommendations for nutrition intervention in SLE resulted in only a moderate recommendation for the consumption of omega-3 PUFAs. The systematic reviews and meta-analyses addressed animal/fish products, experimental diets, minerals/vitamins/supplements, and plant-based diets.52 While the EULAR recommendations are limited, a healthful diet, such as the Mediterranean diet, including omega-3 PUFA foods, is important. Due to the increased incidence of CVD in individuals with SLE, strategies in addition to pharmacological treatment should include alterations in lifestyle; smoking cessation; an antihypertensive diet, such as the DASH diet; and weight control.57

Nutrition Counseling for SS
Education is focused on the primary aspects of the disease, such as dry mouth, and other secondary concomitant conditions, including RA or SLE. Patients with dry mouth are at increased risk of bacterial overgrowth and dental decay and therefore should be advised to sip water frequently during the day and night. They should use dentist recommended fluoride toothpastes, and abstinence from sugary foods and drinks will minimize plaque and bacterial growth.41

The Mediterranean diet is postulated to help with SS due to the anti-inflammatory foods consumed. Meals including red wine, fish, olive oil, high-fiber fruits and vegetables, and fewer red meats and processed foods are thought to be beneficial. Other proposed approaches include exclusion diets (eg, gluten-free, autoimmune protocol, anti-inflammatory), but they lack valid data and aren’t recommended.48 A recent review by VenHuizen addressed supplementation with omega-3 and omega-6 PUFAs, curcumin, and vitamins A, D, C, and E and determined that quality data supporting their intake are missing. Correction of any nutrient deficiency is appropriate, but not expected to improve symptoms in SS.17 Interestingly, individuals without SS following the Mediterranean diet were found to be less likely to develop SS primarily due to the omega-3 PUFAs from fish and olive oil in the diet.58

Nutrition Counseling for Scleroderma
Clinicians should do a nutrition assessment of individuals with scleroderma that addresses organ involvement and their overall wellbeing and serve as a guide for dietary choices. Suboptimal nutrient intake secondary to chronic inflammation of the entire gastrointestinal tract can result in malnutrition. Recommendations for dietary manipulation to address reflux, gastroparesis, and dysphagia have been promoted, yet quality interventional studies are lacking. Burlui and colleagues studied the nutritional intake of 42 people with scleroderma to evaluate their risk of malnutrition, including weight loss, and serum proteins, such as albumin and C-reactive protein. Their findings reinforced the need for qualified nutrition counseling.59

Gastrointestinal symptoms include bloating, diarrhea, and constipation. Indigestion, dysphagia, and fecal incontinence may need to be addressed. Nutrient malabsorption secondary to gut dysbiosis also should be of concern.25 Unfortunately, there’s limited evidence suggesting that therapeutic dietary manipulation affects disease progression.53 And while there’s no unique scleroderma diet, the need for quality nutrition is important. Consumption of anti-inflammation foods with quality nutrient profiles are recommended. Sequential nutrition assessments for protein malnutrition, vitamin and mineral imbalances, and gut dysbiosis is essential to prevent or correct malnutrition. Some patients have benefitted from a diet low in FODMAPs to minimize intestinal bloating, diarrhea, and constipation.60

Nutrition Counseling for Gout
Naturally occurring purine in food is digested and absorbed into the blood. The metabolized byproduct is uric acid, which in gout can result in hyperuricemia. A low purine diet with pharmaceutical management is designed to reduce serum uric acid levels.61 Certain foods increase the risk of gout including seafood (eg, anchovies, sardines, tuna, mussels, cod, scallops, trout, haddock), red meats (eg, beef, bacon, veal, venison, organ meats), turkey, sweetened beverages (especially high fructose corn syrup), alcohol (beer and distilled spirits), and yeast and yeast extracts.

Conversely, a lower risk of gout incidence, including flares, resulted with consumption of low-fat dairy products, folate-rich foods, coffee, vitamin C, cherries, and increased\water consumption. One downside is that the seafood limitation reduces anti-inflammatory omega-3 PUFAs. Supplementation with fish oils rich in omega-3 PUFAs is suggested.61 Weight loss is essential in the prevention and management of gout. Reducing body fat decreases serum levels of uric acid and reduces the stress on joints. The prevalence of comorbid conditions such as type 2 diabetes, hypertension, obesity, sleep apnea, and CVDs warrants nutrition counseling addressing these conditions as well as nutrition modifications for gout.44,62

Pharmacological Management of Common IRDs
The development of new drugs for the treatment of IRDs has resulted in significant improvements in patients’ quality of life. Traditional remedies for pain and inflammation include nonsteroidal anti-inflammatory drugs, nonnarcotic and narcotic analgesics, and corticosteroids. Newer stalwart medications for IRDs include DMARDs and biologic response modifiers, or biologic DMARDs. The mechanism of action of DMARDs varies depending on the agent. Common actions involve blocking key steps in the inflammatory response or inhibiting lymphocyte proliferation.63 Methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide are examples of the more common DMARDs.

Biologics were introduced in the 1990s and are effective because of their targeted ability to inhibit proliferation of inflammatory cytokines (TNF, IL-1, IL-6), genetic activation of T-cells (CTLA-4), and B lymphocytes. They’re indicated when traditional therapies, such as DMARDs, are unsuccessful.44,64 New medications called biosimilars are being developed, which are duplicates of biologics, yet they’re made from living cells, and may have slight variations interacting with the immune system. The FDA has approved biosimilars in the management of RA, ankylosing spondylitis, and psoriatic arthritis.4

Physical and Occupational Therapy Management
Physical conditioning inhibits inflammation and should be included in lifestyle guidance for patients with IRDs.65 Recurring systemic inflammation, common in IRDs, is associated with greater cardiovascular risk, sarcopenia, insulin resistance, and neurodegeneration, often producing a cycle of inactivity that exacerbates concomitant diseases and chronic inflammation.66 Maintaining physical strength, especially with the assistance of physical and occupational therapists, improves activities of daily living by adjusting daily tasks to protect joints and avoid functional loss. For example, therapeutic hand exercises are beneficial in preventing contractures.25,67 People with spondylarthritis improve through consistent exercise, including stretching, strengthening, aerobic, and balance training. The discovery of myokines and correlating immunomodulatory effects of physical activity supports exercise recommendations. A recent German study found that aerobic exercise such as dancing, cycling, walking, and swimming improved cardiopulmonary status, while tai chi and yoga helped balance, and strength training assisted mobility and stabilization.68

Research Gaps
Significant improvement in the diagnosis and pharmacological treatment of IRDs in recent years has benefitted many patients. However, the impact of nutrition on IRDs hasn’t been adequately researched, and many of the studies from controlled clinical trials are questionable and of poor quality.48 Gwinutt’s 2022 literature review of 174 studies on seven rheumatic diseases determined that there isn’t a particular nutrient or diet that supports remission or clinically significant improvement in IRDs. They concluded there’s a need for expanded research, including long-term follow up on the role of nutrition and IRDs.52

The role of gut dysbiosis resulting in leaky gut is hypothesized to be partially responsible for the inflammation in some IRDs. The use of prebiotic and probiotic foods as well as supplementation with Lactobacillus and Bifidobacterium, which restores gut microbiota in some studies, warrants further research.69

The causal relations between hyperuricemia and comorbid disorders such as hypertension, CVD, and other features of metabolic syndrome are hotly debated, but they also are inadequately researched. Novel foods such as cherry juice extracts also warrant further clinical trials to determine their efficacy in decreasing gout attacks.44,70 None of the IRDs discussed have been adequately researched to specifically include nutrition intervention in treatment plans except for gout.

Putting It Into Practice
The clinician is challenged with which diet to recommend to patients with IRDs. Should the diet involve weight loss, supplementation with omega-3 PUFAs, be the Mediterranean diet, or exclude foods like gluten, meat, and alcohol? Unfortunately, there’s no specific diet that’s effective in altering the disease’s progression. There are, however, opportunities to reduce symptoms for the various IRDs, primarily using anti-inflammatory foods. One exception would be the low-purine diet for gout. While the diet won’t stop the progression, it can help minimize the gouty arthritis flares often experienced.

Nutrition assessments to determine risks and direct care plans are essential. A primary goal for nutrition management should include weight loss if warranted and replacement of deficient nutrients. Many IRDs have symptoms such as bloating, diarrhea, constipation, fatigue, and osteoporosis, which can benefit from dietary intervention. Diseases such as systemic sclerosis can affect the entire gastrointestinal tract and require specialized nutrition care. Concomitant diseases such as diabetes, inflammatory bowel disease, and celiac also require nutrition care plans that manage the unique aspects of these conditions. The role of the gut and the immune system is still being elucidated. There’s building evidence that a leaky gut is at least contributory, if not causative, of inflammation. The Mediterranean diet has added benefits for gastrointestinal and cardiovascular health. The plant-based mix of fruits, vegetables, whole grains, fish, olive oil, and legumes is beneficial in building a healthy gut flora.71,72

IRDs challenge clinicians’ medical management due to the complexity of the diseases and corresponding treatment plans. While new drugs are critical in slowing or stopping disease progression, the role of nutrition in the care plan is essential to support the patient’s overall health, reduce inflammation, and address nutrition risk factors.

— Tony Pipkin, MS, RDN, is an Arkansas-based freelance writer focused on nutrition and autoimmune disorders.


Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Distinguish between the common inflammatory rheumatic diseases (IRDs).
2. Develop appropriate care plans based on nutrition assessments for IRDs.
3. Educate patients with IRDs on the potential nutritional benefits of special diets and supplements.
4. Identify IRDs lacking evidence for nutrition intervention.


1. Sjögren’s syndrome afflicts postmenopausal women vs men by what ratio?
a. 2:1
b. 5:1
c. 9:1
d. 20:1

2. Bechterew’s disease is another name for which inflammatory rheumatic disease (IRD)?
a. Systemic lupus erythematosus
b. Systemic scleroderma
c. Amyotrophic lateral sclerosis
d. Ankylosing spondylitis

3. Which organization provided a grade A recommendation for the Mediterranean diet in the management of rheumatoid arthritis?
a. American College of Rheumatology
b. French Society for Rheumatology
c. Dutch Society of Rheumatology
d. American Rheumatology Network

4. Which of the following is the most common IRD?
a. Systemic lupus erythematosus
b. Rheumatoid arthritis
c. Spondyloarthropathies
d. Gout

5. Localized scleroderma, which only affects the skin, is also known as which of the following?
a. Hyperhidrosis
b. Onychogryphosis
c. Podagra
d. Morphea

6. This form of inflammatory arthritis, which afflicts 4% of US adults, is attributable to hyperuricemia.
a. Juvenile idiopathic arthritis
b. Sjögren’s syndrome
c. Enteropathic arthritis
d. Gout

7. Most patients with spondyloarthropathies have a gene that produces which antigen, that in combination with a trigger, such as bacteria, initiates an inflammatory response?
a. Interleukin-1
b. HLA-B27
c. HLA-D12
d. Tumor necrosis factor

8. Which IRD can affect the entire gastrointestinal tract?
a. Systemic sclerosis
b. Psoriatic arthritis
c. Enteropathic arthritis
d. Sjögren’s syndrome

9. Which of the following is associated with enteropathic arthritis?
a. Irritable bowel syndrome
b. Hirschsprung disease
c. Gastroesophageal reflux disease
d. Whipple disease

10. Approximately what percentage of patients with psoriasis develop psoriatic arthritis?
a. 10%
b. 25%
c. 30%
d. 47%


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22. Rheumatoid arthritis. American College of Rheumatology website. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis. Updated December 2021. Accessed September 14, 2022

23. The Lupus Initiative website. https://thelupusinitiative.org/. Accessed August 22, 2022.

24. Scleroderma. American College of Rheumatology website. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Scleroderma. Updated December 2021. Accessed September 1, 2022.

25. Scleroderma. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/scleroderma/symptoms-causes/syc-20351952. Updated January 27, 2022. Accessed August 23, 2022.

26. Frisell T, Hellgren K, Alfredsson L, Raychaudhuri S, Klareskog L, Askling J. Familial aggregation of arthritis-related diseases in seropositive and seronegative rheumatoid arthritis: a register-based case-control study in Sweden. Ann Rheum Dis. 2016;75(1):183-189.

27. Barut K, Adrovic A, Şahin S, Kasapçopur Ö. Juvenile idiopathic arthritis. Balkan Med J. 2017;34(2):90-101.

28. Salaffi F, Di Carlo M, Carotti M, Farah S, Ciapetti A, Gutierrez M. The impact of different rheumatic diseases on health-related quality of life: a comparison with a selected sample of healthy individuals using SF-36 questionnaire, EQ-5D and SF-6D utility values. Acta Biomed. 2019;89(4):541-557.

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