Nutrient Intake in Postmenopausal Rheumatoid Arthritis Women with Osteoporosis: Results from the Korean National Health and Nutrition Examination Survey

Yeon Soo Baik; Jee Won Park; Jihye Kim; Won Gyoung Kim; Sohee Oh; Sung-il Cho; Yeong Wook Song; Kichul Shin

doi:10.4078/jrd.2017.24.1.35

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Baik, Park, Kim, Kim, Oh, Cho, Song, and Shin: Nutrient Intake in Postmenopausal Rheumatoid Arthritis Women with Osteoporosis: Results from the Korean National Health and Nutrition Examination Survey

Original Article

J Rheum Dis 2017;24(1):35-42.

Published online: 31 October 2017

DOI: https://doi.org/10.4078/jrd.2017.24.1.35

Nutrient Intake in Postmenopausal Rheumatoid Arthritis Women with Osteoporosis: Results from the Korean National Health and Nutrition Examination Survey

Yeon Soo Baik¹, Jee Won Park¹, Jihye Kim², Won Gyoung Kim³, Sohee Oh⁴, Sung-il Cho⁵, Yeong Wook Song⁶, Kichul Shin²

¹Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA

²Division of Rheumatology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea

³Department of Nutrition Service, SMG-SNU Boramae Medical Center, Seoul, Korea

⁴Department of Biostatistics, SMG-SNU Boramae Medical Center, Seoul, Korea

⁵Graduate School of Public Health, Seoul National University, Seoul, Korea

⁶Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

Corresponding to: Kichul Shin, Division of Rheumatology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea. E-mail: kideb1@snu.ac.kr

Received 22 September 2016 Revised 15 January 2017 Accepted 3 February 2017

This is a Open Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

Osteoporosis (OP) is one of the principal comorbidities in women with rheumatoid arthritis (RA). Proper nutrition for these patients is required not only to improve bone health but to better manage their chronic illness. Thus, our aim was to assess the status of key nutrient intake in postmenopausal RA women with OP.

Methods

Using cross-sectional data of 4,933 postmenopausal women in the Korean National Health and Nutrition Examination Survey (K-NHANES IV, V) conducted between 2008 and 2011, we investigated the daily nutrient intake in RA subjects and their bone mineral density (BMD). We examined the association of nutrient intake and BMD after adjusting age, level of education, body mass index, family history, alcohol use, and total calorie intake in the osteoporosis, osteopenia, and normal BMD group using multivariable linear regression.

Results

We included 222 RA women and 320 controls whose BMD and T-score data were available. Low calcium and phosphorous intake were associated with reduced BMD T-scores in postmenopausal RA women. Additionally, β-carotene, potassium, riboflavin, and vitamin C intake were significantly lower in RA women with OP. Multivariable linear regression analysis showed a strong positive association of intake of β-carotene, potassium, riboflavin, and calcium with higher T-scores at the lumbar spine, femur neck, and total hip (all p＜0.0001, respectively).

Conclusion

We found insufficient intake of nutrients such as β-carotene, potassium, riboflavin, and vitamin C in Korean postmenopausal RA women with low BMD. Dietary counseling and recommendations are warranted for these subjects to attain better bone health.

Keywords: Bone density, Nutrition surveys, Osteoporosis, Rheumatoid arthritis

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Figure 1.

Scheme of the study subject selection process. K-NHANES: Korean National Health and Nutrition Examination Survey, DXA: dual energy X-ray absorptiometry, RA: rheumatoid arthritis, OA: osteoarthritis, BMD: bone mineral density.

Table 1.

Demographics and characteristics of postmenopausal women with rheumatoid arthritis divided into 3 groups

Variable	OP (n=100)	ON (n=98)	NL (n=24)
Age (yr)	68.5±0.7	62.3±0.6	57.8±1.1
Age of menopause (yr)	49.0±0.8	48.5±1.0	49.5±2.4
Monthly income
1st tertile	44 (37.3)	31 (25.6)	5 (14.4)
2nd tertile	36 (36.7)	45 (46.3)	10 (42.2)
3rd tertile	20 (26.0)	20 (28.1)	9 (43.4)
Education level
Primary or lower	88 (84.4)	66 (56.3)	12 (51.0)
Middle school	4 (3.7)	21 (26.0)	5 (21.0)
High school	6 (8.0)	10 (16.5)	6 (25.8)
College or higher	2 (3.9)	1 (1.2)	1 (2.2)
Marital status
Married	50 (52.5)	62 (63.5)	18 (81.6)
Single	50 (47.5)	35 (36.5)	5 (18.4)
Family history of OP	11 (10.3)	17 (17.6)	3 (9.0)
Residential area
Urban	46 (51.3)	45 (54.4)	13 (54.6)
Rural	54 (48.7)	53 (45.6)	11 (45.4)
High-risk alcohol user^∗	16 (22.0)	26 (37.7)	6 (25.5)
Current smoker^†	4 (2.9)	4 (3.3)	1 (3.7)
BMI (kg/m²⁾	22.4±0.2	24.0±0.2	25.8±0.5
Waist circumference (cm)	78.6±0.7	81.5±0.6	86.7±1.8
Whole body fat mass (kg)	51.1±0.6	56.2±0.4	63.6±1.3
Whole body total lean mass (kg)	34.0±0.3	36.6±0.3	40.2±0.7

Values are presented as mean±standard error or number (%). OP: osteoporosis, ON: osteopenia, NL: normal bone mineral density, BMI: body mass index.

^* The fraction of drinkers whose average volume of alcohol consumption exceeds 280 mL or whose pattern of drinking is more than twice a week.

^† The fraction of current smokers who have smoked over 100 cigarettes for life.

Table 2.

Comparison of daily nutrient intake among the 3 groups in postmenopausal women with rheumatoid arthritis^∗

Variable	OP (n=100)	ON (n=98)	NL (n=24)	p-value
Variable	OP (n=100)	ON (n=98)	NL (n=24)	Overall group comparison	OP vs. ON	OP vs. NL	ON vs. NL
Total calorie (kcal)	1,471.89±1.06	1,475.87±1.04	1,423.96±1.07	NS	NS	NS	NS
Protein (g)	47.04±1.09	46.63±1.08	48.25±1.10	NS	NS	NS	NS
Fat (g)	17.72±1.11	18.17±1.10	18.74±1.13	NS	NS	NS	NS
Carbohydrate (g)	269.67±1.08	265.68±1.07	258.48±1.08	NS	NS	NS	NS
Calcium (mg)	319.00±1.12	361.91±1.12	390.68±1.16	NS	NS	NS	NS
Phosphorous (mg)	837.57±1.08	845.73±1.07	899.73±1.08	NS	NS	NS	NS
Sodium (mg)	2,816.64±1.13	2,977.09±1.10	3,145.41±1.14	NS	NS	NS	NS
Potassium (mg)	2,064.62±1.08	2,330.64±1.07	2,552.17±1.09	0.0124	0.0231 (NS)	0.0051	0.1691 (NS)
Iron (mg)	10.59±1.12	11.54±1.11	11.35±1.16	NS	NS	NS	NS
Vitamin A (μ g)	346.82±1.18	462.94±1.19	560.88±.44	NS	0.0410 (NS)	NS	NS
Thiamin (mg)	0.84±1.06	0.85±1.06	0.91±1.05	NS	NS	NS	NS
Riboflavin (mg)	0.66±1.07	0.80±1.07	0.86±1.10	0.0048	0.0027	0.0061	NS
Niacin (mg)	10.79±1.08	11.16±1.08	11.37±1.10	NS	NS	NS	NS
Vitamin C (mg)	65.75±1.12	83.74±1.14	83.63±1.18	0.0216	0.0081	NS	NS
β-carotene (μ g)	1,718.49±1.20	2,572.16±1.19	3,002.80±1.36	0.0176 (NS)	0.0071	0.0418	NS
Retinol (μ g)	14.82±1.26	15.85±1.32	19.42±1.44	NS	NS	NS	NS

Values are least square mean±standard error. OP: osteoporosis, ON: osteopenia, NL: normal bone mineral density, NS: non-significant.

^* Multivariate linear regression was performed after adjusting for age, education, body mass index, family history, and alcohol use. Additionally, all nutrients other than total calorie intake were adjusted for total calorie intake.

Table 3.

Multivariate linear regression analysis of the relationship between nutrient intake and bone mineral density T-scores (n=222)^∗

Variable	Lumbar spine T-score			Femur neck T-score			Total hip T-score
Variable	β	SE	p-value	β	SE	p-value	β	SE	p-value
β-carotene (μ g)	2,312.76	±373.18	＜0.0001	1,908.87	±388.47	＜0.0001	1,287.48	±304.68	＜0.0001
Potassium (mg)	198.32	±48.76	＜0.0001	187.27	±72.97	0.0114	124.49	±57.29	0.0316
Riboflavin (mg)	0.14	±0.02	＜0.0001	0.08	±0.03	0.0088	0.07	±0.02	0.0031
Calcium (mg)	46.18	±14.09	0.0013	73.66	±15.57	＜0.0001	60.33	±13.57	＜0.0001
Vitamin C (mg)	7.36	±4.28	0.0874	10.50	±5.43	0.0556	6.62	±5.25	0.2101
Phosphorous (mg)	25.31	±12.95	0.0527	32.02	±12.54	0.0118	45.55	±10.58	＜0.0001
Iron (mg)	0.37	±0.49	0.4513	0.21	±0.61	0.7337	−0.40	±0.42	0.3439
Thiamin (mg)	0.03	±0.01	0.0537	0.01	±0.01	0.5582	0.02	±0.01	0.1816
Niacin (mg)	0.40	±0.20	0.0517	0.23	±0.23	0.3419	0.16	±0.18	0.3735

SE: standard error.

^* Analysis was performed after adjusting for age, education, body mass index, family history, and alcohol use.

Supplementary Table 1.

Demographics and characteristics of postmenopausal women in rheumatoid arthritis and non-arthritis subjects

Variable	Rheumatoid arthritis (n=242)	Non-arthritis (n=320)	p-value
Age (yr)	64.2±0.7	64.0±0.8	0.8823
Monthly income			0.4347
1st tertile	83 (27.6)	89 (22.4)
2nd tertile	103 (43.9)	144 (48.4)
3rd tertile	54 (28.5)	70 (29.2)
Education level			0.0656
Primary or lower	182 (67.7)	229 (67.7)
Middle school	32 (15.1)	39 (14.5)
High school	24 (15.0)	31 (9.8)
College or higher	4 (2.2)	21 (7.9)
Marital status			0.7493
Married	142 (42.2)	189 (61.9)
Single	98 (43.8)	125 (38.1)
Family history of OP	33 (14.5)	56 (17.2)	0.7377
Residential area			0.0020
Urban	118 (55.6)	198 (70.4)
Rural	124 (44.4)	122 (29.6)
High-risk alcohol user	51 (29.2)	72 (24.5)	0.3387
Current smoker	9 (2.9)	11 (3.5)	0.6643
BMI (kg/m²)	23.6±0.23	24.1±0.22	0.0977

Values are presented as mean±standard error or number (%). OP: osteoporosis, BMI: body mass index.

Supplementary Table 2.

Daily nutrient intake in rheumatoid arthritis versus non-arthritis subjects

Variable	Rheumatoid arthritis (n=222)	Non-arthritis (n=320)	p-value
Total calorie (kcal)	1,446.21±1.04	1,391.03±1.04	0.4734
Protein (g)	45.69±1.08	45.43±1.09	0.9359
Fat (g)	16.94±1.12	17.14±1.12	0.7144
Carbohydrate (g)	257.24±1.07	258.22±1.07	0.7253
Calcium (mg)	348.35±1.12	314.91±1.12	0.1099
Phosphorous (mg)	843.20±1.08	831.81±1.08	0.7787
Sodium (mg)	3,022.38±1.15	2,826.52±1.15	0.2429
Potassium (mg)	2,244.86±1.09	2,174.60±1.09	0.6457
Iron (mg)	10.91±1.11	10.19±1.10	0.3344
Vitamin A (μ gRE)	413.89±1.10	381.84±1.07	0.5428
Thiamin (mg)	0.84±1.08	0.83±1.08	0.984
Riboflavin (mg)	0.75±1.11	0.69±1.12	0.1762
Niacin (mg)	10.51±1.09	10.76±1.08	0.4835
Vitamin C (mg)	70.36±1.16	61.69±1.16	0.1337
β-carotene (μ g)	2,075.38±1.11	1,926.38±1.08	0.5731
Retinol (μ g)	22.03±1.21	17.72±1.17	0.3579

Values are least square mean±standard error. All nutrients other than total calorie intake were adjusted for total calorie intake.

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