Rev. Bras. Reumatol. vol.56 número2

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w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Original

article

Food

intake

assessment

and

quality

of

life

in

women

with

fibromyalgia

夽

Emmanuelle

Dias

Batista

a,∗

,

Aline

Andretta

a

,

Renata

Costa

de

Miranda

b

,

Jéssica

Nehring

c

_,

_Eduardo

_dos

_Santos

_Paiva

a

_,

_Maria

_Eliana

_Madalozzo

_{Schieferdecker}

b

a_Hospital_de_Clínicas,_Universidade_Federal_do_Paraná_(UFPR),_Curitiba,_PR,_Brazil

b_{Post-Graduate}_Program_on_Food_and_Nutrition_Security,_Universidade_Federal_do_Paraná_(UFPR),_Curitiba,_PR,_Brazil

c_Universidade_Federal_do_Paraná_(UFPR),_Curitiba,_PR,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received27August2014 Accepted2March2015

Availableonline11September2015

Keywords:

Fibromyalgia Qualityoflife Pain Foodintake Foodregistration

a

b

s

t

r

a

c

t

Objective:Tocomparethefoodintakeofwomenwithandwithoutfibromyalgiaandverify

ifthefoodintakeofpatientswithfibromyalgiainterfereswiththepainandqualityoflife.

Methods:Studyparticipantswerewomenwithfibromyalgia(FM)seeninFibromyalgia

Out-patientClinic,HospitaldasClínicas/UFPRandacontrolgroup(CT)withhealthywomen. DatacollectionwasconductedfromMarchtoOctober2012.Fortheassessmentoffood intakeweusedtheFoodRegistrationandtheanalyzeditemsweretotalcalories, carbohy-drates,proteins,lipids,vitamins(A,C,B12,DandE)andminerals(folate,selenium,zinc, iron,calciumandmagnesium).ThesoftwareusedwasAvanutriOnline®_._To_evaluate_the qualityoflife,theFibromyalgiaImpactQuestionnaire(FIQ)andpainthresholdwereused.

Results:43patientswithFMand44healthywomenwereevaluated.CTgroupshoweda

meanconsumptionofnutrientsgreaterthanFMgroupexceptforiron.However,onlycaloric intake,carbohydrates,proteinsandlipidsingramsandpercentageoflipids,vitaminA,E, B12,folate,seleniumandcalciumwerestatisticallysignificant.InFMgroup,therewasa neg-ativecorrelationbetweenvitaminEandFIQandapositivecorrelationbetweenpercentage ofproteinandpainthreshold.

Conclusion: WomenwithFMshowedalowerqualitativeandquantitativeintakein

compar-isonwithCTgroup.OnlyvitaminEcorrelatedwithqualityoflifeandpercentageofprotein inthedietwithsensationofpain.

夽

StudyconductedatDepartmentofNutrition,EndocrinologyandRheumatology,UniversidadeFederaldoParaná(UFPR),Curitiba,PR, Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](E.D.Batista). http://dx.doi.org/10.1016/j.rbre.2015.08.015

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Avaliac¸ão

da

ingestão

alimentar

e

qualidade

de

vida

de

mulheres

com

fibromialgia

Palavras-chave:

Fibromialgia Qualidadedevida Dor

Ingestãoalimentar Registroalimentar

r

e

s

u

m

o

Objetivo:Compararaingestãoalimentardemulherescomesemfibromialgiaeverificarsea

ingestãoalimentardaspacientescomfibromialgiainterferenasensac¸ãodedorequalidade devida.

Métodos:Participaramdoestudomulherescomfibromialgia(FM)atendidasnoAmbulatório

deFibromialgiadoHospitaldeClínicas/UFPReparaogrupocontrole(CT)foramconvidadas mulheressaudáveis.Acoletadedadosfoifeitademarçoaoutubrode2012.Paraaavaliação doconsumoalimentarfoiusadooRegistroAlimentareositensanalisadosforam:calorias totais,carboidratos,proteínas,lipídeos,vitaminas(A,C_,_B12,_D_e_E)_e_minerais_(folato,_selênio, zinco,cálcio,ferro emagnésio).OsoftwareusadofoioAvanutriOnline®.Paraavaliação daqualidadedevidafoiusadooQuestionáriodeImpactodaFibromialgia(FIQ)elimiar doloroso.

Resultados: Foramavaliadas43pacientescomFMe44 mulheressaudáveis.OgrupoCT

apresentouconsumomédiodenutrientessuperioraogrupoFM,comexceçãoparaoferro. Entretanto,somenteaingestãocalórica,carboidratos,proteínaselipídeosemgramas, por-centagemdelipídios,vitaminaA,E,B12,folato,selênioecálcioforamestatisticamente significativas.NogrupoFMhouvecorrelaçãonegativaentrevitaminaEeFIQecorrelação positivaentreporcentagemdeproteínaelimiardoloroso.

Conclusão: AsmulherescomFMapresentaramingestãoqualitativamentee

quantitativa-menteinferioraogrupoCT.SomenteavitaminaEapresentoucorrelac¸ãocomaqualidade devidaeaporcentagemdeproteínanadietacomasensac¸ãodedor.

Introduction

Fibromyalgia(FM)isoneofthemostfrequentrheumatic dis-eases.InBrazil,FMaffectsabout2–3%ofthepopulation, usu-allyappearbetween30and35yearsofageandismore com-monamongwomen.1,2_According_to_the_{classification}_criteria

oftheAmericanCollegeofRheumatology,thedefinitionofthis syndromeusestwovariables:Bilateralpainaboveandbelow thewaistplusaxialpainandawidespreadchronicpainover threemonths’duration,andpainonpalpationofatleast11 of18specificsitesinthebody,knownastenderpoints.3

Together with the pain, these patients often have a

decreaseintheirqualityoflifeduetosymptomssuchassleep disturbances,fatigue,morningstiffness,subjectivesenseof accumulationofbodyfluids,extremityparesthesias, depres-sion,headache,dizzinessandboweldisorders.1,2

Althoughitsetiologyandpathogenesisarenotknown,

evi-dence suggests that some individuals may have a genetic

predisposition to this disease when exposed to certain

environmental factors.Studies suggest involvement ofthe hypothalamus–pituitary–adrenalaxisandtheautonomic

ner-vous system in response to stress in patients showing

vulnerabilityforthisdisease,oritssymptoms.4–6

Theeatinghabitsofthesepatientsareimportant,the

rea-sonforwhichstudieshaveshownimprovementinsymptoms

ofthediseasewithabalancedandhealthydiet.7–10

VegetariandietsappeartoalleviatesomesymptomsofFM, andthismaybeduetotheirlowfatandproteincontent,high levelsoffiber,vitaminC,betacarotene,minerals(magnesium,

potassium,zinc,selenium) and antioxidants.8 _According_to

the Brazilian Society ofRheumatology,care mustbe taken withnutritioninFMpatients,forinstance,reducingthe con-sumptionofsugar,salt,fatand alcoholand increasingthe intakeoffiber,fruits,vegetablesandfluidsinordertoavoid theappearanceofotherchronicdiseasesandofoverweight.9

Specificmicronutrientssuchascalcium(Ca)andmagnesium (Mg)areimportantinmusclecontractions,forhelpingto

pro-duce muscle spasms and nerve impulses.Evidence shows

thatincreasingintakeoffoodsourcesoftryptophancanbe beneficial,becausethisaminoacidplaysaroleinserotonin synthesis.10

Thestrategyforthetreatmentoffibromyalgiarequiresa multidisciplinaryapproach,withorwithoutpharmacological treatment.

The aimofthis study is tocompare the food intakeof womenwithandwithoutfibromyalgiaandverifyifthefood intakeoffibromyalgiapatientsinterfereswiththeirperception ofpainandwithqualityoflife.

Patients

and

methods

Thisisananalytical,cross-sectional,observationalstudy.The projectwasapprovedbytheHumanResearchEthics Commit-teeofHospitaldasClínicas,UniversidadeFederaldoParaná

(CEP-HC/UFPR). Female patients diagnosed with

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the same age group were invited. All womenin the study signedanInformedConsentForm.Theexclusioncriteriain

the study were medication change in the last four weeks,

useofcorticosteroidsandvitaminsupplements,unbalanced hypothyroidism, being pregnant or breastfeeding, illiterate women,andfoodregistrationnotfilled.Datacollectiontook placebetweenMarchandOctober2012.

Fortheassessmentoffoodconsumption,aFoodRegistry wasused.Eachvolunteerwasinstructedtoregisterthree non-consecutivedaysofdieting(twoweekdaysandoneweekend day)andshouldincludedetailedfoodsorpreparations.Later the data were tabulated in the Avanutri Online® _software andthemean3-dayintakewasadjustedtoreduce intraper-sonalandinterpersonalvariation.Theitemsexaminedwere total calories, carbohydrates, proteins, lipids, vitamins (A, C,B12,D andE)and minerals(folate, selenium,zinc,iron, calciumandmagnesium).Toassesstheadequacyof macronu-trients(carbohydrates,proteinsandlipids),AMDR(Acceptable MacronutrientDistributionRange)11 _was_used _as_the _base;

forvitaminsandminerals,EAR(EstimatedAverage Require-ments)wasused.12,13

Toanalyze the subjects’ quality oflife,the participants completedtheFibromyalgiaImpactQuestionnaire(FIQ).14_FIQ

assesses how muchthe disease interferes withday-to-day

activitiesthroughascorefrom 0to100.Thus,thecloserto 100,thegreatertheimpactofthediseaseonqualityoflife.

Tomeasurepainthreshold,theFisheralgometer,adevice thatdeterminestheintensityofpressureonaparticulararea, wasused.Inthisstudy,theareausedtochecktheintensityof painenduredbythesubjectwastherighttrapeziusmuscle. Themeasurementswereperformedintriplicatebythesame examiner.

Thenutritionalstatusofthestudyparticipantswas mea-suredusingtheBodyMassIndex(BMI),accordingtotheWorld HealthOrganization(WHO1998).15_To_calculate_the_height,_we

usedaTonelli&Gomesstadiometer.Bodyweightwas mea-suredwiththeparticipantswearingtheminimumamountof clothesonaportabledigitalscalewithamaximumcapacity of150kg.

Forstatisticalanalysis,theMann–WhitneyUtestwasused todetectdifferencesbetweenmeansofnon-parametricdata,

and Spearman correlation was appliedfor non-parametric

data.Rsoftwareversion2.11.1(2010-5-31)Statgraphics Cen-turion and SPSSStatistics 17.0were usedinthe statistical analysis.Thelevelofsignificancewassetatp≤0.05.

Results

103womenwereevaluatedinthisstudy;ofthistotal,16were excludedforlackofdataontheirFoodRegister.Thefinal sam-pleconsistedof43patientswithfibromyalgiaand44controls. AgeandBMIweresimilarinbothgroups,whilepainthreshold, FIQandcalorieintakeweresignificantlydifferent(Table1).

TheproperdistributionofmacronutrientsinthedietofFM patientswas88.37%(n=38)forcarbohydrates(CHO),97.67% (n=42)forproteins(PTN),and74.42%(n=32)forlipids(LIP). Ontheotherhand,incontrolgroup,86.36%(n=38)ofpatients exhibitedasuitabledistributionofCHO,100%(n=44)ofPTN, and79.55%(n=35)ofLIP.InFMgroup,inadequateintakeof micronutrientswaspresentinover65%ofpatients,exceptfor

consumptionofironandselenium,with100%ofadequacy.

InCTgroup,themicronutrientsthatshowedthehighest per-centageofadequacywereseleniumwith100%andironwith 77.27%.Folateintakewasinappropriatein100%andtheother micronutrientspresentedlowintakepercentagesofadequacy (Table2).

When CHO, PTN and LIP intake (in g) was compared

betweenFMversusCTgroup,astatisticaldifferencewasnoted.

However, whenthe percentage ofadequacy ofthesesame

nutrientswascompared,onlyLIPshoweddifference(Table3). Asformicronutrientintake,CTgroupshowedanadjusted meanintakehigherthanFMgroup,exceptforiron.Vitamin A,E,B12,folate,selenium,calciumandironintakesshoweda statisticallysignificantdifference(Table4).

InthecorrelationsofFIQandpainthresholdversus

nutri-ent intake in FM group, it was observed that vitamin E

showed amoderateand negativecorrelationwithFIQ, and

%PTNpresentedamoderateandpositivecorrelationwithpain threshold(Table5).

Discussion

FMandCTgroupsshowednostatisticaldifferenceinthe vari-ablesageandBMI,revealinghomogeneity.Asexpected,FIQ andpainthresholdvaluesweredifferent,butthecontrolgroup foodintakewashigherwithrespecttocalories.

FMgrouphadaloweradjustedmeanintakeof macronutri-ents(ingrams),vitaminsandmineralsversusCTsubjects,with theexceptionofiron.However,vitaminA,E,B12,folate, sele-niumandcalciumintakeswerestatisticallysignificant.The

Table1–Samplecharacterization.

FM(n=43) Mean±SD

CT(n=44) Mean±SD

p-Value

Age 49±7.92 46.8±10.36 0.4911

BMI(kg/m2₎ _26.96_±_4.64 _25.72_±_3.76 _0.1841

Painthreshold(kg/cm2₎ _2.87_±_0.76 _5.33_±_1.65 _<0.0001a

FIQ(0–100) 69.12±18.85 8.63±10.78 <0.0001a

kcal 1442.5±409 1752±451.1 0.0024a

FM,fibromyalgiagroup;CT,controlgroup;SD,standarddeviation;BMI,BodyMassIndex;FIQ,FibromyalgiaImpactQuestionnaire;p-value,value oftheprobabilityassociatedwiththetestedstatistics.

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Table2–Theadequacyoffoodintakeoffibromyalgiapatientsandcontrols.

FM CT

Intake Reference

value

Suitable %(n)

Inadequate %(n)

Suitable %(n)

Inadequate %(n)

CHO(%) 45–65 88.37(38) 11.63(5) 86.36(38) 13.64(6)

PTN(%) 10–35 97.67(42) 2.33(1) 100(44) –

LIP(%) 20–35 74.42(32) 25.58(11) 79.55(35) 20.45(9)

VitaminA(␮g/d) 500 13.95(6) 86.05(37) 29.55(13) 70.45(31)

VitaminC(mg/d) 60 23.26(10) 76.74(33) 45.45(20) 54.55(24)

VitaminD(␮g/d) 10 – 100(43) 2.27(1) 97.73(43)

VitaminE(mg/d) 12 9.3(4) 90.7(39) 2.27(1) 97.73(43)

VitaminB12(␮g/d) 2 30.23(13) 69.77(30) 47.73(21) 52.27(23)

Folate(␮g/d) 320 – 100(43) – 100(44)

Selenium(␮g/d) 45 100(43) – 100(44) –

Zinc(mg/d) 6.8 32.56(14) 67.44(29) 29.54(13) 70.46(31)

Calcium(mg/d) 800/1000a _2.33₍₁₎ _97.67₍₄₂₎ _4.55₍₂₎ _95.45₍₄₂₎

Iron(mg/d) 8.1/5b ₁₀₀₍₄₃₎ _– _77.27₍₃₄₎ _22.73₍₁₀₎

Magnesium(mg/dl) 255/265c _– ₁₀₀₍₄₃₎ _2.27₍₁₎ _97.73₍₄₃₎

FM,fibromyalgiagroup;CT,controlgroup;%CHO,carbohydrateintakepercentage;PTN%,proteinintakepercentage;LIP%,lipidintake percent-age;n,numberofpatients.

a _19–50_years:₈₀₀_mg/d_and_>51_years:₁₀₀₀_mg/d. b _19–50_years:_8.1_mg/d_and_>51_years:₅_mg/d. c _19–30_years:₂₅₅_mg/d_and_>31_years:₂₆₅_mg/d.

Table3–Macronutrientfoodintakeinfibromyalgiaandcontrolgroups.

AMDR FM(n=43)

Mean±SD

CT(n=44) Mean±SD

p-Value

Carbohydrates(g) – 191.79±62.05 226.48±65.06 0.0152a

Carbohydrates(%) 45–65 52.95±6.33 51.72±5.56 0.4474

Proteins(g) – 58.57±18.97 68.5±17.9 0.0102a

Proteins(%) 10–35 16.5±3.57 15.87±3.2 0.2136

Lipids(g) – 45.78±17.28 61.05±20.45 0.0007a

Lipids(%) 20–35 28.15±5.69 31.01±4.96 0.0214a

FM,fibromyalgiagroup;CT,controlgroup;SD,standarddeviation;AMDR,AcceptableMacronutrientDistributionRanges;p-value,valueofthe probabilityassociatedwiththetestedstatistics.

a _{Statistically}_significant_difference₍_p_<_0.05)_between_FM_and_CT_groups_with_{Mann–Whitney}_test.

Table4–Micronutrientfoodintakeinfibromyalgiaandcontrolgroups.

EAR FM(n=43)

Mean±SD

CT(n=44) Mean±SD

p-Value

VitaminA(␮g/d) 500 302.7±231.29 446.14±274.03 0.0021a

VitaminC(mg/d) 60 49.47±29.27 66.9±51.73 0.2571

VitaminD(␮g/d) 10 1.78±1.65 2.04±1.98 0.4348

VitaminE(mg/d) 12 6.58±3.83 10.29±0.87 <0.0001a

VitaminB12(␮g/d) 2 1.96±2.2 2.4±1.85 0.0359a

Folate(␮g/d) 320 83.29±55.27 101.27±0.05 0.0015a

Selenium(␮g/d) 45 48.46±0.07 51.97±0.09 <0.0001a

Zinc(mg/d) 6.8 5.67±2.59 5.75±2.36 0.8221

Calcium(mg/d) 800/1000b _404.13_±_235.53 _510.87_±_210.2 _0.0428a

Iron(mg/d) 8.1/5c _11.64_±_0.23 _9.52_±_3.78 _<0.0001a

Magnesium(mg/dl) 255/265d _135.84±58.87 149.86±49.9 0.1712

FM,fibromyalgiagroup;CT,controlgroup;SD,standarddeviation;EAR,EstimatedAverageRequirement;p-value,valueoftheprobability associatedwiththetestedstatistics.

a _{Statistically}_significant_difference₍_p_<_0.05)_between_FM_and_CT_groups_with_{Mann–Whitney}_test. b _19–50_years:₈₀₀_mg/d_and_>51_years:₁₀₀₀_mg/d.

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Table5–Relationshipamongfoodintake,FIQandpainthresholdinFMgroup.

FIQ Painthreshold

r p-Value r p-Value

Kcal −0.032 0.837 −0.171 0.273

PTN(g) −0.005 0.976 0.180 0.247

PTN(%) 0.129 0.410 0.358 0.018a

CHO(g) −0.122 0.437 −0.247 0.111

CHO(%) −0.166 0.287 −0.147 0.345

LIP(g) −0.063 0.688 −0.126 0.421

LIP(%) −0.104 0.506 −0.019 0.901

VitaminA(␮g/d) −0.131 0.403 −0.005 0.975

VitaminC(mg/d) 0.189 0.224 −0.160 0.305

VitaminD(␮g/d) 0.05 0.749 0.106 0.498

VitaminE(mg/d) −0.303 0.048a _0.198 _0.203

VitaminB12(␮g/d) 0.253 0.102 −0.025 0.875

Folate(␮g/d) 0.018 0.910 0.159 0.310

Selenium(␮g/d) −0.068 0.665 −0.187 0.229

Zinc(mg/d) 0.176 0.260 0.159 0.310

Calcium(mg/d) −0.085 0.587 0.200 0.200

Iron(mg/d) 0.191 0.221 0.064 0.685

Magnesium(mg/dl) 0.207 0.183 0.185 0.236

FIQ,FibromyalgiaImpactQuestionnaire;PT,painthreshold;r,correlationcoefficient;p-value,valueoftheprobabilityassociatedwiththetested statistics.

a _{Statistically}_significant_difference₍_p_<_0.05),_with_Spearman_correlation.

resultsindicatethatFMpatientspresentedqualitativelyand quantitativelylowerintakesversusCTsubjects.

Thecombinationoftheantioxidantsfoundinvitaminsand mineralswithanalgesicagentscanreducethedosesofthese drugsandconsequentlyimprovethesensationofpainofFM patients.Itwasalsodemonstratedthatantioxidantsare criti-calinreducingtheoxidativestressinducedbyFM.16_Based_on

thisstudy,itwasnotedthatapropernutritionalguidancefor thesepatientscandecreasethesymptomsofthedisease.

Inmost ofthe FM subjects, aninadequate ingestion of vitaminCwasobserved.Richardetal.16_showed_that_the

pro-longeduseofanalgesicscanincreasetheexcretionofvitamin Candpotassium,causing,asaresult,irondeficiencyanemia. WomenwithFMexhibitedanadequateintakeofiron,andthe presenceofanemiawasnotassessedinthisstudy. Maintain-ingahealthyandbalanceddietwithvitaminsandmineralsis importanttominimizefuturedeficiencyintheirbloodlevels. WhenpainthresholdandFIQwererelatedtofoodintake

ofFMpatients,vitaminEshowedamoderateand negative

correlationwithFIQ,indicatingthatthehighertheintakeof thisvitamin,thebetterwouldbethequalityoflife.Studies showthatantioxidant-richdietsimprovethesymptomsofFM bypromotingvasodilation.Katzetal.17_explain_that_the_pain

inFMmightoccurduetovasomotordysregulation,whichin turncausesmusclehypoperfusion.

InthestudybySakaryaetal.,18_the_authors_evaluated_blood

levelsofantioxidantvitaminsandmagnesiumandcorrelated withclinical parametersofFM. Theauthors foundno cor-relationbetweenvitaminsA,C,EandMglevels,numberof tenderpoints,painseverity,functionalabilityanddepression inpatientswithFM.Theresultssuggestthatpoorintakeof thesenutrientsdonotnecessarilysignifylowbloodlevels.

%PTNinthenutritionofFMwomenhadamoderateand

positive correlation with pain threshold, showing that the

higher the proteinpercentage,the greater the toleranceto pain.PatientswithFMshowedPTNintakewithinAMDR rec-ommendations,andarguablyifthispercentagewereoutside normalrange,theresultwould notbethesame.Thestudy byShiavonandPortero19 _evaluated_protein_origin,

conclud-ing that the lower consumptionofanimal proteinand the

higherconsumptionofvegetableprotein,associatedwiththe

consumption of fruits, vegetables and legumes, provide a

healthierstatetobodytissues.Butourstudydidnotassessthe ingestedPTNquality;thus,itwasnotpossibletocheckifthe intakeofPTNofdifferentoriginswouldinterferedifferently inpainthreshold.

A relationship between food intake and pain was also

foundinthestudybyBelletal.20_;_these_authors_found_that

folateandvitaminB12areessentialforregulationofcentral nervoussystem,andthattheirdeficiencyresultsin periph-eralneuropathypain.WhilevitaminCdeficiencycancause myalgiaandbonepain,vitaminDdeficiencycancause mus-culoskeletalpain.

Althoughtherelationshipoftheotherstudiednutrientsin improvingthequalityoflifeandpainsensitivityhasalready beenestablished,inourstudy,wecould notverifyany sta-tisticalcorrelation,possiblyduetothesmallsamplesizeor becauseofahighlyinadequateintakeofseveral micronutri-ents.

FM isa chronicdisease that manifestsitself differently frompersontoperson,affectingthequalityoflifeofpatients

thankstophysicalandpsychologicalsymptoms.The

phar-macologicaltreatmentaloneisinadequateformostpatients; thus,multidisciplinary approaches havebeen usedin clin-ical practice. Studies have shown that the combination of

moderate physical activity and supplementation/intake of

antioxidants may be beneficial, because this combination

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Conclusion

WomenwithFMexhibitedaqualitativelyandquantitatively

lower intakeversus CTsubjects. Vitamin Eshowed a

mod-erateandnegativecorrelationwithqualityoflifeand with percentageofproteininthediet,andamoderateand posi-tivecorrelationwithpainthreshold.Theseresultsshowthe

importance of a proper and healthy nutrition to improve

FM symptoms. More studies are needed to determine the

potentialassociationbetweenclinicalparametersofFMand macronutrientandmicronutrientintake.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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