Bootsma, H.

Jager-Wittenaar, H.

Kroese, F. G. M.

Vissink, A.

English

ARTS repository - University of Groningen

   University of GroningenUndernutrition and sarcopenic obesityJager-Wittenaar, H.; Vissink, A.; Kroese, F. G. M.; Bootsma, H.Published in:Clinical and Experimental RheumatologyIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Jager-Wittenaar, H., Vissink, A., Kroese, F. G. M., & Bootsma, H. (2021). Undernutrition and sarcopenicobesity: underrecognised conditions in patients with Sjögren's syndrome? Clinical and ExperimentalRheumatology, 39(6), S20-S22. https://www.clinexprheumatol.org/pubmed/find-pii.asp?pii=34596029CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 14-02-2023S-20 Clinical and Experimental Rheumatology 20211Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen;2Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen;3Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, the Netherlands.Harriët Jager-Wittenaar, RD, PhDArjan Vissink, DDS, MD, PhDFrans G.M. Kroese, MD, PhDHendrika Bootsma, MD, PhDPlease address correspondence to:Harriët Jager-Wittenaar,Department of Oral and Maxillofacial Surgery,University Medical Center Groningen,P.O. Box 30.001, 9700 RB Groningen, The Netherlands.E-mail: h.jager@umcg.nlReceived on May 28, 2021; accepted in revised form on July 26, 2021.Clin Exp Rheumatol 2021; 39 (Suppl. 133): S20-S22.© Copyright CliniCal and ExpErimEntal rhEumatology 2021.Key words: Sjögren’s syndrome, malnutrition, sarcopenia, obesity, muscleCompeting interests: none declared.IntroductionSjögren’s syndrome (SS) is a chronic, systemic autoimmune disease affecting the exocrine glands (1). Clinical mani-festations of pSS include dry mouth and related problems like poor dental status, swallowing problems, and loss of taste and smell. Because of the reduced sali-va production, many patients with pSS experience problems with food intake. Patients with pSS may have difficulty with swallowing hard and sticky food products (2). They need additional flu-ids to enable food transport in the mouth and oesophagus. Moreover, the lack of saliva often results in rampant caries and tooth loss (2). The poor dental sta-tus may further hinder eating hard food products. From other patient popula-tions, e.g. patients with head and neck cancer, it is known that oral symptoms like dry mouth, swallowing and chew-ing problems, and poor dentition may impact dietary intake, especially pro-tein intake. These oral symptoms have been associated with malnutrition (3-5).pSS also affects the digestive tract di-rectly. Gastrointestinal dysmotility that is characterised by reflux and passage problems in the oesophagus, stomach and intestines is also frequently present in patients with pSS (6). Dysfunction of the liver and pancreas may further disturb the digestive process (7). These symptoms and manifestations of the di-gestive tract hinder adequate intake and absorption of both macro- and micronu-trients, and may thus result in malnu-trition, characterised by loss of muscle mass. In addition, other manifestations, like fatigue, a prominent symptom in patients with pSS (8, 9) that may result from psychological distress, anaemia, or inflammation (8, 10), as well as sys-temic inflammation and systemic treat-ment like anti-inflammatory therapy with corticosteroids (e.g. prednisone) (11) may contribute to loss of muscle mass. Recently, it was demonstrated that patients with pSS have a low intake of ω-3 and ω-6 fatty acids, and that higher levels of serum ω-3 (α-linolenic acid and docosahexaoanic acid) corre-late with lower ocular symptoms and disease activity, thus suggesting a pos-sible role of chronic inflammation (12). From other populations with rheuma-toid diseases, chronic inflammation is known to contribute to loss of muscle mass (13). Whether malnutrition is re-flected by the observed change in intes-tinal microbiota in pSS patients (14), and herewith contributes to the disease progress, remains to be further studied. Undernutrition and sarcopenic obesityMalnutrition can present as two dif-ferent phenotypes, i.e. undernutrition or sarcopenic obesity. Undernutrition has been defined as “a state resulting from lack of intake or uptake of nutri-tion that leads to altered body composi-tion (decreased fat free mass) and body cell mass leading to diminished physi-cal and mental function and impaired clinical outcome from disease” (15). To diagnose undernutrition, the Global Leadership Initiative on Malnutrition (GLIM) criteria have been developed (16). According to the GLIM criteria, undernutrition is present if at least one of the phenotypic criteria and at least one etiologic criterion is present (Fig. 1). While a consensus-based definition for sarcopenic obesity is lacking, it is primarily characterised by low muscle mass in combination with excess of fat mass (17). In practice, excess of fat mass is considered when the BMI is ≥30 kg/m2. It remains unclear to which extent patients with pSS are under-nourished or have sarcopenic obesity.Malnutrition may result in a negative EditorialUndernutrition and sarcopenic obesity: underrecognised conditions in patients with Sjögren’s syndrome?H. Jager-Wittenaar1,2, A. Vissink1, F.G.M. Kroese3, H. Bootsma3S-21Clinical and Experimental Rheumatology 2021Malnutrition in Sjögren’s syndrome / H. Jager-Wittenaar et al.spiral, because malnutrition is known to be associated with poorer clinical outcomes including lower tolerance of systematic therapy (18) and lower quality of life (19, 20). The decrease in muscle mass may contribute to or even increase fatigue, which may result in reduced physical activity in patients with pSS (21), which in turn may result in further loss of muscle mass due to disuse muscle atrophy (11).Besides becoming undernourished, loss of muscle can also be accompanied by obesity. In a study in 39 patients with pSS classified according to the 2016 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria, we found a body mass index (BMI) of 25±5 kg/m2, indicating that 95% of the population has a BMI between 15 kg/m2 and 35 kg/m2 (22). This find-ing suggests that in addition to under-weight (i.e. BMI<18.5 kg/m2, a char-acteristic of undernutrition), obesity (i.e. BMI≥30 kg/m2) is also prevalent in patients with pSS (22). In the same study, we also found that a fair amount of patients with pSS use an unhealthy diet (22). In the same study, patients completed the Dutch Healthy Diet Food Frequency Questionnaire (DHD-FFQ). The DHD-FFQ is an instrument that evaluates intake of physical activity, vegetables, fruit, dietary fibre, saturated fatty acids, trans fatty acids, consump-tion occasions with acidic drinks and foods, sodium and alcohol. In our study, we found a mean score of 56±12, which on group level was above the cut-off for a healthy diet, i.e. 53 points but lower than DHD-FFQ scores of the Dutch population, i.e. 68.7±16.1 for men and 79.4±16.0 for women (23). This score of 56±12 in our study also indicated that a fair amount of the patients with pSS scored below the cut-off for a healthy diet. The unhealthy diet may be accompanied by higher energy intake, suggesting that the obesity may be re-lated to the dietary pattern of the patient with pSS. Knowledge gap on dietary intake in patients with Sjögren’s syndromeSince malnutrition (i.e. undernutrition or sarcopenic obesity) is known to neg-atively impact daily functioning, qual-ity of life, and healthcare costs (19, 20, 24), adequate dietary intake, and main-tenance of muscle mass and muscle function are of utmost importance in patients with pSS. However, thus far, studies that focused on dietary intake and nutritional status in patients with pSS are scarce, characterised by small study samples and showing conflicting data. Studies from Norway (25) and New Zealand (26) reported that dietary intake among patients with SS does not differ from recommended intake and did not alter body composition (24). On the contrary, an American study showed that women with pSS (n=24) had higher energy intake than healthy controls (27). Also a study in older pa-tients with SS (n=28) reported multiple nutrient deficiencies including energy, protein, vitamin A, C, B1, B2, B6, fi-bre, iron, calcium and zinc (28).What to do?To enable improvement of quality of life of patients with pSS, it is of utmost importance to elucidate the relationship between diet, nutritional status, and the potential relationship with disease man-ifestations of patients with pSS. Better insight in the diet and nutritional status of these patients, as well as understand-ing how pSS-related factors influence food choices, will help to develop a per-sonalised dietary treatment for patients with pSS. This insight and understand-ing will improve dietary intake and optimise nutritional status including muscle status. Moreover, it has to be as-sessed whether changes in the oral mi-crobiome, intestines or both play a role and if so, how they can be influenced.For daily practice, we recommend to include nutritional risk screening and nutritional assessment in the routine work up of patients with pSS at diag-nosis and follow up. The nutritional Fig. 1. Recommended nutritional risk screening, nutritional assessment and treatment of patients with pSS.BMI: body mass index; GLIM: Global Leadership Initiative on Malnutrition (16).S-22 Clinical and Experimental Rheumatology 2021Malnutrition in Sjögren’s syndrome / H. Jager-Wittenaar et al.screening and assessment serve as basis to identify nutrition impact symptoms, i.e. oral and systemic disease manifes-tations that hinder food intake, to di-agnose nutrition-related disorders like undernutrition and sarcopenic obesity, and to initiate multimodal treatment in-cluding dietary treatment and exercise to improve muscle status (Fig. 1).References  1. GOLDBLATT F, O’NEILL SG: Clinical aspects of autoimmune rheumatic diseases. Lancet 2013; 382: 797-808.  2. JENSEN SB, VISSINK A: Salivary gland dys-function and xerostomia in Sjögren’s syn-drome. Oral Maxillofac Surg Clin North Am 2014; 26: 35-53.  3. JAGER-WITTENAAR H, DIJKSTRA PU, VIS-SINK A, van der LAAN BF, van OORT RP, ROODENBURG JL: Critical weight loss in head and neck cancer--prevalence and risk factors at diagnosis: an explorative study. Support Care Cancer 2007; 15: 1045-50.  4. 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Undernutrition and sarcopenic obesity:underrecognised conditions in patients with Sjögren's syndrome?

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Undernutrition and sarcopenic obesity:underrecognised conditions in patients with Sjögren's syndrome?

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