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Minor impact of juvenile arthritis on nutritional status in young adult patients.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 47, No. 6, December 15, 2002, pp 623– 629
DOI 10.1002/art.10799
© 2002, American College of Rheumatology
ORIGINAL ARTICLE
Minor Impact of Juvenile Arthritis on
Nutritional Status in Young Adult Patients
MARGARETHA A. HAUGEN, GUNHILD LIEN, BERIT FLATØ, JANNE A. KVAMMEN, ODD VINJE,
DAG SØRSKAAR, AND ØYSTEIN FØRRE
Objective. Growth abnormalities and poor nutritional status have been reported in children with juvenile idiopathic
arthritis (JIA). The aim of this study was to evaluate the impact of juvenile chronic rheumatic disease on current
nutritional status in adult patients in remission or with active disease.
Methods. One hundred thirty-eight women and 82 men, aged >20 years, with JIA were studied after a mean disease
duration of 15.5 ⴞ 2.3 years. Eighty-four (61%) of the women and 49 (60%) of the men were in remission. Forty-one
healthy women and 54 healthy men served as a reference group. Body composition was analyzed by dual-energy x-ray
absorptiometry.
Results. There was no difference in height or body mass index (BMI) between patients and healthy subjects. However,
female patients with systemic disease had significantly reduced BMI compared with those with pauciarticular JIA (P <
0.001), and female patients who used or had been using corticosteroids had significantly lower weight, height, and BMI
compared with the patients who had never used corticosteroids (P < 0.05). Female patients in remission had significantly
more lean body mass compared with healthy controls (P < 0.05) and significantly less body fat was found in both women
and men (P < 0.01 for both). Patients with active disease had the same amount of lean body mass as the healthy controls,
but significantly less body fat (P < 0.05 for women and P < 0.01 for men).
Conclusion. Adult patients with JIA had attained normal height, weight, and BMI, with the exception of women with
systemic JIA and those who were using or had used corticosteroids. Patients with JIA in remission seemed to have a better
nutritional status than healthy subjects.
KEY WORDS. Juvenile arthritis; Nutritional status; Body mass index; Lean body mass; DEXA.
INTRODUCTION
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory process that affects the joints, synovial tissue, and
bursa. Concomitant poor nutritional status has been reported, which is indicated by reduced muscle mass, low
serum albumin concentration, unbalanced iron metabolism, and reduced antioxidant defense (1– 4). These features have been shown to be the results of increased production of tumor necrosis factor ␣ and interleukin-1 (4,5).
Supported by grants from the Research Council of Norway, MEDINNOVA at the National Hospital, the Oslo Women’s Public Health Association, and the Eimar Munthe Memorial Foundation.
Margaretha A. Haugen, RD, PhD, Gunhild Lien, MD, Berit
Flatø, MD, PhD, Janne A. Kvammen, RD, Odd Vinje, MD,
PhD, Dag Sørskaar, MD, PhD, Øystein Førre, MD, PhD, Professor: Rikshospitalet, Sognsvannsveien, Norway.
Address correspondence to Margaretha Haugen, Center
for Rheumatic Diseases, Rikshospitalet, Sognsvannsveien
20, Norway. E-mail: margaretha.haugen@fhi.no.
Submitted for publication August 28, 2001; accepted in
revised form March 29, 2002.
In addition, it is possible that reduced physical activity
during childhood affects the anthropometric variables in
children with JIA (6).
Because childhood and adolescence are the periods of
body growth, interference with nutritional status during
these years may have implications for height, weight, and
body composition in adulthood. The aim of this study was
to evaluate the influence of juvenile chronic rheumatic
disease during childhood and adolescence on current nutritional status in adult patients in remission or with active
disease.
PATIENTS AND METHODS
Patients. The patients included in the present study had
previously been diagnosed with idiopathic arthritis of at
least 6 weeks’ duration and met the criteria for JIA (Table
1) (7). All patients had been hospitalized for the first time
at the Center for Rheumatic Diseases at Rikshospitalet,
Oslo, Norway between January 1980 and September 1985.
Of 400 total patients with JIA diagnosed during this pe623
624
Haugen et al
Table 1. Subgroups of patients with juvenile arthritis
(JA)*
All JA Active
In
patients disease remission
Women
Number
Pauciarticular
Polyarticular
Systemic
Psoriatic arthritis
Juvenile ankylosing
spondylitis
Syndrome of seronegative
enthesopathy and
arthropathy
Arthritis in inflammatory
bowel disease
Men
Number
Pauciarticular
Polyarticular
Systemic
Psoriatic arthritis
Juvenile ankylosing
spondylitis
Syndrome of seronegative
enthesopathy and
arthropathy
138
66 (48)
42 (30)
6 (4)
13 (9)
2 (1)
54
20 (37)
21 (38)
1 (2)
6 (11)
2 (4)
84
46 (55)
21 (25)
5 (6)
7 (8)
6 (4)
2 (4)
4 (5)
3 (2)
2 (4)
1 (1)
82
29 (35)
18 (22)
8 (10)
11 (13)
8 (10)
33
9 (27)
9 (27)
3 (9)
3 (10)
5 (15)
49
20 (41)
9 (18)
5 (10)
8 (16)
3 (6)
8 (10)
4 (12)
4 (8)
* Data presented as number (%) unless otherwise noted.
riod, 336 (84%) participated in the study, which was conducted in 1997. Of the 64 patients (16%) who did not take
part, 8 had died, 12 chose not to participate, 5 had left the
country, and the addresses of 39 could not be found. The
findings in patients ⬍ 20 years of age were excluded from
this report, because there were no age-matched controls.
The final number of participants was 220: 138 women
and 82 men. Mean age (⫾ SD) and mean disease duration
(⫾ SD) were 24.9 ⫾ 2.9 and 15.6 ⫾ 2.4 years in the women
and 25.2 ⫾ 3.1 and 14.1 ⫾ 2.1 years in the men.
At the time of investigation, 84 (61%) of the women and
49 (60%) of the men had a history of JIA. This was defined
as being in remission, with no disease activity, and these
subjects had not taken medication for the previous 6
months (Table 2). The mean duration of remission (⫾ SD)
was 8.2 ⫾ 4.5 years and 10.2 ⫾ 4.2 years in the women and
men, respectively. The mean duration of active disease
(⫾ SD) in these patients was 7.3 ⫾ 4.9 years for the women
and 4.8 ⫾ 4.0 years for the men. Patients with persistent
JIA were defined as having active disease at the time of
investigation. In the groups of patients with active disease,
the mean (⫾ SD) disease duration was 15.7 ⫾ 2.7 years in
women and 15.0 ⫾ 2.1 years in men. Eight male and 20
female patients had high disease activity at the time of
investigation, which was defined as having ⬎ 5 swollen
joints and/or an erythrocyte sedimentation rate (ESR) ⬎ 28
mm/hour.
Ninety-five (41 females, 54 males) healthy subjects were
recruited from 2 military camps in the Oslo area. The
subjects had no known disease that was ascertained by a
physical exam. Seventeen (41%) of the female group were
military employees and 50 (93%) of the male group were
military employees. The mean ages (⫾ SD) were 27.4 ⫾ 3.2
years for the women and 25.8 ⫾ 2.9 years for the men
(Table 2).
The study was approved by the Regional Ethics Committee for Medical Research, and informed consent was
obtained from all the participants.
Table 2. Characteristics of patients with juvenile arthritis (JA) and healthy subjects*
Women
Number
Age at inclusion, years
Age at disease onset, years
Disease duration, years
Arthritis severity index, median (range)
Use of steroids
Never used, n (%)
Used earlier, n (%)
Current medication, n (%)
Men
Number
Age at inclusion, years
Age at disease onset, years
Disease duration, years
Arthritis severity index, median (range)
Use of steroids
Never used, n (%)
Used earlier, n (%)
Current medication, n (%)
Active
disease
In
remission
Healthy
subjects
54
24.9 ⫾ 2.8
9.5 ⫾ 3.1
15.7 ⫾ 2.7
13 (0–160)
84
25.4 ⫾ 2.7
9.8 ⫾ 3.1
7.3 ⫾ 4.9
0 (0–52)
41
27.3 ⫾ 3.2
NR
NR
NR
32 (59)
13 (24)
9 (17)
73 (87)
11 (13)
33
25.5 ⫾ 3.4
9.8 ⫾ 3.3
15.0 ⫾ 2.1
7 (0–52)
49
25.2 ⫾ 2.9
10.3 ⫾ 3.3
4.8 ⫾ 4.1
0 (0–61)
19 (58)
5 (15)
9 (27)
38 (78)
11 (22)
* Data presented as mean ⫾ SD unless otherwise noted. NR ⫽ not relevant.
54
25.8 ⫾ 2.9
NR
NR
NR
Nutritional Status in JIA
625
Table 3. Anthropometric and laboratory measurements in adults with juvenile arthritis
and healthy subjects*
Women
Number
Height, cm
BMI, kg/cm2
Lean body mass, kg
Body fat, %
ESR, mm/hour
Hemoglobin, gm/liter
Albumin, gm/liter
Men
Number
Height, cm
BMI, kg/cm2
Lean body mass, kg
Body fat, %
ESR, mm/hour
Hemoglobin, gm/liter
Albumin, gm/liter
Active disease
In remission
Healthy subjects
54
166.8 ⫾ 6.6
23.0 ⫾ 4.1
42.7 ⫾ 5.5
28.4 ⫾ 9.6†
20 ⫾ 19‡§
1.23 ⫾ 0.12¶
41.0 ⫾ 4.3§
84
167.2 ⫾ 5.5
23.7 ⫾ 4.7
45.1 ⫾ 6.1†
26.2 ⫾ 11.4‡
9⫾6
1.32 ⫾ 0.09†
43.6 ⫾ 3.0‡
41
168.6 ⫾ 6.8
23.8 ⫾ 3.6
42.1 ⫾ 5.0
33.3 ⫾ 7.9
8⫾5
1.25 ⫾ 0.08
41.4 ⫾ 2.2
33
179.8 ⫾ 5.9
23.5 ⫾ 2.6
61.9 ⫾ 6.5
13.7 ⫾ 7.3‡
14 ⫾ 20‡§
1.46 ⫾ 0.12
43.9 ⫾ 5.2§
49
180.7 ⫾ 7.8
24.4 ⫾ 3.8
64.0 ⫾ 6.7
12.9 ⫾ 11.0‡
4⫾3
1.50 ⫾ 0.09
47.1 ⫾ 2.9‡
54
181.0 ⫾ 6.2
24.8 ⫾ 2.4
61.0 ⫾ 5.5
20.1 ⫾ 6.5
3⫾2
1.46 ⫾ 0.08
44.6 ⫾ 2.3
* Data presented as mean ⫾ SD, unless otherwise noted. BMI ⫽ body mass index; ESR ⫽ erythrocyte
sedimentation rate.
† P ⬍ 0.05 between patient groups and healthy subjects.
‡ P ⬍ 0.01 between patient groups and healthy subjects.
§ P ⬍ 0.05 between patients in remission and patients with active disease.
¶ P ⬍ 0.001 between patients in remission and patients with active disease.
Measurements. Estimated body fat and estimated lean
mass were evaluated by means of dual-energy x-ray absorptiometry (DEXA; Lunar Expert, Lunar Radiation Corporation, Madison, WI). Daily quality tests were run with
a phantom, and only 2 technicians were used. The coefficient of variation of bone mineral density measurements
was ⬍1.5% at the setting we used. The same technician
and physician certified all scans.
Because some of the patients had had prosthetic replacements in different joints, these measurements were only
made in 77 of the male patients and 128 female patients.
All the participants were weighed (W) on a digital scale to
the nearest kilogram, and the height (H) was measured to
the nearest centimeter. Body mass index (BMI) was calculated by W/H2. Underweight was defined as BMI ⬍ 20 for
men and BMI ⬍ 19 for women. Overweight was defined as
BMI ⬎ 25 for men and BMI ⬎ 24 for women, and obese was
defined as BMI ⬎ 30 for both women and men (8).
The Westergren ESR, hemoglobin concentration, serum
albumin, and total serum calcium were measured by routine laboratory methods. Serum 25-hydroxyvitamin D was
measured by means of a competitive protein-binding assay. The arthritis severity index was calculated on the
basis of a clinical examination. This index, which is the
sum of the graded values for joint swelling, tenderness,
and limited range of motion, has been found to be a good
predictor of the development of severe disease (9).
Food and nutrient intake were estimated by means of a
quantitative food frequency questionnaire, which has been
validated for this age group (10,11). The questionnaire was
optically read and the calculations fully computerized in
accordance with the Norwegian Food Composition Table
(12). Physical activity was quantified on a 6-part scale, in
which daily physical activity for 20 minutes or more was
rated 6 and none or very rare physical activity was rated 1.
Physical activity in this context was defined as perspiring
and becoming short of breath.
Statistical analysis. Statistical analysis was performed
with the SPSS for Windows statistical package, 8th edition
(SPSS Inc., Chicago, IL). The data are given as means ⫾ SD.
The Kolmogorov–Smirnov test was used to determine the
normality of the data before statistical tests that require a
Gaussian distribution were performed. One-way analysis
of variance with Bonferroni corrections was run to evaluate group differences of patients with active disease, in
remission, and healthy subjects in variables with a Gaussian distribution. Independent sample t-tests were then
used to compare groups. Kruskal–Wallis test was run to
evaluate differences between groups of patients with active disease, in remission, and healthy subjects of variables
of non-normality, and Mann–Whitney U test was used to
test differences between groups. The latter test was also
used for measurements on ordinal scale (physical activity).
The Pearson correlation coefficient was calculated to test
the association between 2 variables with a Gaussian distribution, and Spearman’s rank correlation coefficient was
used in cases of non-normal distribution.
RESULTS
There was no statistically significant difference between
the patient groups with high and low disease activity, the
patients in remission, and the healthy controls in mean
height and BMI, (Table 3). However, the female patients
626
Haugen et al
with active disease than in the healthy subjects. In addition, the percentage of unsaturated fat was higher in the
patients with active disease than in the healthy subjects
(P ⬍ 0.05). The same was seen in the female group, but the
difference was not statistically significant. The patients
with active disease had a significantly higher intake of
whole-fat milk and mayonnaise than the controls, whereas
the healthy subjects had a higher intake of skim milk. As a
consequence of the higher fat intake, vitamin D and vitamin E intake was also higher in the patients with active
disease than in the healthy subjects. Mean sugar intake
constituted 9 –10% of the total energy intake in all groups.
Supplementation was as common in the healthy subjects as in the patient groups. About 20% supplemented
their daily intake with cod liver oil, and 50% of the females and 35% of the males with minerals and/or vitamins.
Fifty-five percent of the women and 67% of the men
with active disease smoked every day as compared with
44% of the healthy subjects and patients in remission.
However, the difference was not statistically significant.
The healthy subjects reported a significantly higher frequency of physical activity than the patient groups (P ⬍
0.05 for the men and P ⬍ 0.01 for the women, KruskalWallis test).
Figure 1. Percentage of underweight, normal weight, overweight,
and obese in patients with juvenile idiopathic arthritis and in
healthy subjects.
DISCUSSION
with systemic JIA had significantly lower weight and BMI
compared with the pauciarticular JIA group (P ⬍ 0.001,
data not shown). The female patients who were using or
had used corticosteroids had significantly lower weight,
height, and BMI compared with patients who had never
used corticosteroids (P ⬍ 0.05 for all). The same findings
were seen in the men, but the differences were not statistically significant. Six male patients (7.5%) and 15 female
patients (11%) were classified as underweight, whereas
none of the healthy subjects were underweight (Figure 1).
Female patients in remission had significantly more total lean body mass than healthy subjects (P ⬍ 0.05). This
difference was still significant when adjusted for height.
The percentage of total body fat was significantly higher in
the healthy subjects compared with the patients in remission (P ⬍ 0.001) and those with active disease (P ⬍ 0.01 in
the female and P ⬍ 0.001 in the male groups; Table 3).
The female patients in remission had significantly
higher hemoglobin concentrations and serum concentrations of albumin than the healthy controls and the patients
with active disease (Table 3). The same was seen in the
male group, but results did not reach statistical significance for the hemoglobin concentration. The serum concentration of calcium was higher in the patient groups
than in the healthy subjects. The potassium concentration
was significantly higher in the patients with active disease
than in the healthy controls (P ⬍ 0.05).
The energy intake per kilogram body weight was higher
in the patient groups than in the healthy subjects, but this
was not statistically significant (Table 4). In the male
group, fat intake was significantly higher in the patients
JIA is a heterogeneous group of chronic inflammatory disorders in which poor nutritional status is often seen (13–
16). Studies have revealed protein energy malnutrition
and low lean body mass with normal to increased fat mass
in children with active disease. A more recent study
showed reduced fat-free mass and a significantly higher
resting energy expenditure (REE) per kilogram body
weight in patients with systemic juvenile rheumatoid arthritis (17). The same study indicated increased REE in
patients with oligo- and polyarticular juvenile rheumatoid
arthritis, but the difference was not statistically significant.
Nutritional supplementation with nocturnal nasogastric
tube feeding has been shown to improve growth and nutritional status in children with JRA, which means that a
greater awareness of healthy eating habits might benefit
patients with active disease (18).
Our aim in this study was to investigate nutritional
status in young adult patients with JIA to evaluate the
impact of the disease during childhood and adolescence.
We did not find that the patients were any less tall than the
healthy subjects. Increased prepubertal growth has also
been reported prior to disease debut in patients with juvenile chronic arthritis compared with healthy peers (19).
Although the patients had a drop in growth velocity the
first year with disease, growth velocity was increased
again after 1 year with treatment. This finding supports our
results. Weight was lower in patients with active disease,
but BMI was similar in patients and healthy subjects (due
to a nonsignificantly lower height). Between 5% and 10%
of the female patients and 6% and 12% of the male patients were underweight, whereas none of the healthy
subjects were underweight. Obesity was as common in the
Nutritional Status in JIA
627
Table 4. Energy and nutrient intake in patients with juvenile arthritis compared with healthy subjects*
Women
Number
Energy intake, kcal
Energy intake, kcal per kg body weight
Protein intake, gm per kg body weight
Fat intake, gm (% of energy intake)
Saturated fatty acids, gm
Monoeneic fatty acids, gm
Polyunsaturated fatty acids, gm
Polyunsaturated fatty acids, % of total energy intake
Sugar, gm
Fiber, gm
Vitamin C, mg
Retinol, equivalents
Vitamin D, ␮g
Vitamin E, mg
Calcium, mg
Magnesium, mg
Iron, mg
Men
Number
Energy intake, kcal
Energy intake, kcal per kg body weight
Protein intake, gm per kg body weight
Fat intake, gm (% of energy intake)
Saturated fatty acids, gm
Monoeneic fatty acids, gm
Polyunsaturated fatty acids, gm
Polyunsaturated fatty acids, % of total energy intake
Sugar, gm
Fiber, gm
Vitamin C, mg
Retinol, equivalents
Vitamin D, ␮g
Vitamin E, mg
Calcium, mg
Magnesium, mg
Iron, mg
Active disease
In remission
Healthy subjects
50
2,132 ⫾ 704
35 ⫾ 14
1.2 ⫾ 0.5
79 ⫾ 32 (33)
31 ⫾ 14
27 ⫾ 11
14 ⫾ 6
5.9 ⫾ 2.0
60 ⫾ 60
21 ⫾ 9
109 ⫾ 68
1,327 ⫾ 806
4.5 ⫾ 3.0
7⫾3
817 ⫾ 268
292 ⫾ 95
10 ⫾ 3
70
2,259 ⫾ 836
36 ⫾ 15
1.2 ⫾ 0.5
80 ⫾ 31 (32)
32 ⫾ 14
28 ⫾ 11
14 ⫾ 6
5.6 ⫾ 1.7
70 ⫾ 83
22 ⫾ 9
128 ⫾ 64
1,314 ⫾ 562
4.1 ⫾ 2.4
8⫾3
859 ⫾ 378
311 ⫾ 92
10 ⫾ 3
40
2,049 ⫾ 591
30 ⫾ 8
1.1 ⫾ 0.3
73 ⫾ 19 (32)
29 ⫾ 14
25 ⫾ 9
12 ⫾ 5
5.2 ⫾ 1.6
53 ⫾ 31
20 ⫾ 6
106 ⫾ 52
1,048 ⫾ 376
3.9 ⫾ 2.2
7⫾2
813 ⫾ 364
292 ⫾ 77
10 ⫾ 2
26
3,161 ⫾ 1,179
43 ⫾ 20
1.5 ⫾ 0.5
129 ⫾ 64 (36)
50 ⫾ 28
45 ⫾ 23
25 ⫾ 13
7.1 ⫾ 2.5†
83 ⫾ 52
24 ⫾ 10
108 ⫾ 58
1,699 ⫾ 744
6.8 ⫾ 3.6
11 ⫾ 6
1,217 ⫾ 569
422 ⫾ 153
13 ⫾ 4
39
3,229 ⫾ 822
42 ⫾ 13
1.4 ⫾ 0.4
121 ⫾ 39 (34)
47 ⫾ 16
42 ⫾ 13
23 ⫾ 11
6.3 ⫾ 2.4
90 ⫾ 54
26 ⫾ 9
144 ⫾ 71
1,606 ⫾ 681
5.9 ⫾ 2.9
11 ⫾ 3
1,263 ⫾ 473
429 ⫾ 108
14 ⫾ 3
51
2,892 ⫾ 694
36 ⫾ 9
1.3 ⫾ 0.3
103 ⫾ 32 (32)
41 ⫾ 13
36 ⫾ 12
18 ⫾ 8
5.4 ⫾ 1.8
71 ⫾ 38
25 ⫾ 9
135 ⫾ 55
1,609 ⫾ 682
5.3 ⫾ 2.5
9⫾3
1,205 ⫾ 398
404 ⫾ 96
14 ⫾ 4
* Data presented as mean ⫾ SD, unless otherwise noted.
† P ⱕ 0.05.
healthy subjects as in the patients. A most interesting
finding was that lean body mass, measured by DEXA, was
significantly higher in patients in remission than healthy
subjects and patients with active disease. Furthermore,
patients with active disease had similar lean body mass
compared with the healthy subjects. Our material might
have been biased, because 16% of the total population did
not participate in this study. There was, however, no difference in sex, onset type, age of diagnosis, or disease
duration between those who chose to participate and those
who did not participate. On the other hand, 5 male and 10
female patients were not measured by DEXA scanning
because of prosthetic replacements in different joints.
These patients were shorter and weighed less than the rest
of the patients, although the differences were not statistically significant.
Our findings are encouraging, because most studies have
shown that children with active disease have less muscle
mass (4,5). Our results may indicate that once the period of
active disease has ended, body growth manages to catch
up. However, patients with systemic disease during adolescence and those using corticosteroids appear to suffer
from sequelae into adulthood.
The healthy subjects who volunteered to participate in
this study were recruited from 2 military bases, and although most of them were doing office work at the time of
investigation, most of the males had had training as military officers. We therefore assumed that our reference
group would be at least as physically fit as our patients,
and they did in fact report a higher frequency of physical
activity than the patients.
Our method evaluating lean body mass by means of
DEXA has been shown to be satisfactory compared with
standard methods, although it may underestimate fat mass
(20,21). Our results are supported by the fact that we found
high lean body mass in patients in remission in both the
female and the male populations. The fact that the patients
in remission had higher lean body mass than either the
628
controls or patients with active disease fits with the higher
serum albumin and hemoglobin concentrations that were
found in this group, although no significant correlations
were found between lean body mass and either serum
albumin or hemoglobin concentration.
The patients with high disease activity had a higher
energy intake per kilogram body weight, though this was
not statistically significant. This agrees with an earlier
study where we reported a higher energy intake per kilogram body weight in patients with high disease activity
compared with patients with low disease activity and
healthy controls (16). It has been shown that patients with
high disease activity have a higher REE, which would
agree with our finding that energy intake has to be increased in this patient group to obtain a normal body
weight (17).
Several earlier studies have documented a reduced concentration of unsaturated fatty acids, especially linoleic
acid, in the phospholipid fraction in patients with active
rheumatic disease (22–28). In our study we found that the
patients with high disease activity had a higher total intake
of unsaturated fat, and this represented a higher percentage of the energy intake. This might mean that patients
with active disease have an unconscious desire for fat,
which could have implications both for studies of supplementation with omega-3 fatty acids and for the development of atherosclerosis (29 –31).
Because both the female and the male patients in remission had a higher lean body mass and less fat than healthy
subjects, it is possible that having a disease during childhood and adolescence increases the individual’s health
awareness. The patient groups are also in frequent contact
with the public health team. However, at the time of this
investigation none of the acquired health variables, such
as physical activity, smoking, and nutrient intake, indicated healthier living habits among patients in remission
than among healthy subjects. On the other hand, adolescents with juvenile chronic arthritis report more overprotection from parents than adolescents in the general population, which indicates closer parental followup (32).
This may lead to a more favorable health outcome later in
life.
From this study, conducted on Norwegian patients with
JIA, it seems that having a chronic rheumatic disease during late childhood and puberty had little impact on nutritional status. However, the patients with the highest disease activity had reduced height and weight, but patients
with a disease activity that did not require use of corticosteroids seemed to have benefited anthropometrically from
the disease, having less body fat and greater muscle mass.
This is an interesting observation that might inspire further investigations.
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