INTRODUCTION:

Osteoarthritis (OA) is the most common of arthritis in the community and chronic disease with unknown etiology. OA has a different etiology but results in the same biological, morphological and clinical outcomes, namely joint pain.¹ This disease is slowly progressive, characterized by changes in the structure of joint cartilage (hyaline cartilage), thickening of the joint bone plates (hyaline cartilage), sclerotic, the appearance of bony prominences on the bony surface of the joint margins (osteophytes)², stretching of the joint capsule, weakening of the supporting muscles of the joint^3,4 subchondral sclerosis, changes in the synovial membrane and joint pain.

The pain, especially in the morning or after inactivity of less than 30 minutes.⁵Changes in the shape and structure of joints can also be caused by increasing age (degenerative).⁶

37% of OA cases occurred in rheumatoid disease, while 97% of them were genu (knee) OA.^7,8 In general, the prevalence of joint disease in Indonesia is very high at 30.3% and the largest is OA. Joint disease disorders in Indonesia are recorded at 8.1% of the total population with the number always increasing to 18.95 in 2018.⁹ OA as a joint disease causes changes in the composition of the joints to compensate for the joint repair process. This can last for several years or decades with marked hypertrophic repair that causes enlargement of chondrocyte cells.¹⁰ As a result of the joint repair process, proteoglycan levels decrease, cartilage becomes soft and loses flexibility.¹¹ Over a long period of time, cartilage will weaken, peeling which causes the joint space to be reduced and narrowed, resulting in crepitus.¹² Joint pain appears which results in a decrease in quality of life because 80% of OA patients have limited movement and 20% cannot perform daily activities.¹³

The incidence of OA is most often found in the elderly group, women¹⁴, obesity, joint trauma, and overworked.¹⁵ The incidence of OA also cannot be separated from social factors such as heavy work, joint injury and malalignment, muscle weakness¹⁵ and low knowledge about OA. The menopausal women’s can increase incidence of osteoporosis.¹⁶ This is due to the state of the weight bearing on the joints.¹⁷ Diet high in sodium is also a risk factor for OA. The role of sodium in the incidence of OA is related to interleukin-17 (IL-17).^18,19 Not many people know that increasing sodium salt concentration will induce T helper-17 (TH-17)^20,21 through activation of the p38/MAPK pathway.²²Th-17 functions to induce IL-17 secretion and is closely related to the process of increasing cartilage catabolism, decreasing chondrocyte secretion, inhibiting aggregation formation and collagen degradation II.²³ IL-17 acts as a potential matrix in causing destruction and inflammation in OA.^24,25,26,27 Damage caused by increased levels of IL-17 causes joint pain. A conclusion in the study reported that functional polymorphisms of IL-17 were significantly associated with the risk of knee OA.²⁸ Increased sodium salt is also a trigger for the formation of inflammation in tissues.²⁹

Sodium is one of the micronutrients needed in the body. Almost all foodstuffs contain sodium, either naturally contained in it or added through the cooking process. The content of sodium salt added in packaged food processing is 10 times greater than the sodium salt added in home processing.^30,31 The National Research Council of the National Academy of Sciences recommends sodium intake of 1100-3300mg per day.³² Globally, 99.2% of the world's adult population has an average sodium intake exceeding 2000mg/day.³³ The results of the Individual Food Consumption Survey, 2014 analysis show that the average sodium intake of adults in Indonesia is 2702mg per day or 2 ,7 grams. Information on the Nutritional Adequacy Rate, 2019 states that for men aged 50-64 years, the limit for sodium needs is 1300mg; women 1400mg and 65-80 years at 1100mg for men; women 1200mg.³⁴

Based on the explanation above, it is necessary to map and analyze data in OA patients related to the pattern of food intake containing sodium salt. This is the first step to identify new risk factors for OA. The study was conducted directly on patients with the aim of knowing the relationship between high levels of sodium in the body and an increase in knee joint pain. Likewise with biopsychosocial factors such as age, gender, Body Mass Index (BMI), occupation and education that can affect OA.

MATERIALS AND METHODS:

Materials:

Indonesian Ministry of Health's Food Model Book, SQ-FFQ (Semi Quantitative Food Frequency Questionnaire) Questionnaire,³⁵ Images of Pain Assessment Tool-VAS (Visual Analog Scale)³⁶ and Software Nutrisurvey Indonesia 2007.

Methods:

This study was an observational with a quantitative descriptive at the Orthopedic Outpatient Poly in level III Hospital of Brawijaya. The sampling method was cross sectional. This research was conducted in April-September 2021 and has obtained hospital permit No. B/404/V/2021 and ethical approval No. 44/LE/2021 from the Faculty of Pharmacy, Universitas Airlangga. The questionnaire used was validated by expert adjustment using the Content Validity Test with the results of the content validity ratio (CVR) = 1. Data collection for the subject was carried out by interview conducted by the researcher.

Research variable:

The dependent variable was joint pain score, biopsychosocial factors (age, gender, BMI, education, occupation) while the independent variable was sodium level. The knee joint pain scores were obtained from the Pain Assessment Tool-VAS image while sodium levels were obtained through the SQ-FFQ Questionnaire. The VAS was divided into 3 categories, namely mild (scores 1-3), moderate (scores 4-6) and severe (scores 7-9). Meanwhile, the SQ-FFQ questionnaire consists of 68 lists of staple foods, vegetables, fruit, animal and vegetable fish, beverages and supporting foods. The list of foods selected was based on demographic data of OA patients at the hospital through a preliminary survey. The diet questions on the SQ-FFQ were divided into daily, weekly and monthly (maximum eating patterns in the previous 3 months). Categories of sodium levels were divided into 3, namely: normal (< 1200mg), moderate (1200-2000mg) and high (> 2000mg). Sodium levels were obtained through the calculation of the Nutrisurvey Indonesia 2007 software. To determine the size/model of the food and drink consumed, it was assisted by photos of the food model.

Tabel 1: Level of Sodium and Knee Joint Pain

Sodium (mg)		Knee Joint Pain
Total score	Category	Score	Category
< 1200	Normal	1_3	mild
1200- 2000	moderate	4_6	moderate
> 2000	Severe	7_9	severe

Research subject criteria:

The inclusions of the study were OA patients with KL grades 1 and 2, aged 40-65 years, male or female, signed the research inform consent, did not smoke 1 pack per day for the last 1 month, did not consume 1 bottle of alcohol per day for the last 1 month. While the exclusion criteria were OA patients with complications of rheumatoid arthritis, spondylitis, psoriasis and gout. Patients who have undergone TKR (Total Knee Replacement), taking sedative-hypnotic drugs, have been injected with Hyaluronan 4 weeks before the study. Research subjects are declared drop out if they were declared to have to stop participating in the study by the doctor in charge of the patient (DPJP) because of an adverse effect harmful. OA patients according to the inclusion criteria were taken data on the intake of sodium levels through the SQ-FFQ then followed by the condition of knee joint pain and biopsychosocial factors.

Statistical analysis:

Univariate analysis contains information about the number of subjects, precentage, the mean and the standard deviation. The data groups that will be presented in this test were sodium levels, VAS scores, bio-psychosocial factors (age, gender, BMI, occupation, education). Multivariate analysis using Partial Least Square (PLS) to determine the relationship and influence between and intervariable research.

RESULTS:

The research subjects obtained were 52 people. The characteristics of the subject's demographic data can be seen in table 2.

Table 2: Demographics of research subjects (n= 52)

Characteristics	Frequency	(%)	Mean ±SD
Gender
Men	8	15.38
Women	44	84.82
Age (years)			57.79±8.09
46-55	22	42.31
56- 65	21	40.38
≥ 66	9	17.31
Body Mass Index (kg/m2)			27.82±4.66
Ideal	14	26.92
Overweight	22	42.31
Obesity	16	30.77
Education
Elementary school	11	21.15
Junior high school	4	7.69
Senior high school	26	50
Bachelor's degree	11	21.16
Occupation
Private	22	42.31
Entrepreneur	19	36.54
Employee	11	21.15

To determine the level of sodium in knee joint pain, researchers have conducted interviews on the subject. The results of the interview can be seen in table 3.

Table 3.Category Sodium Levels and Knee Joint Pain (n=52)

Characteristics	Score	Category	Frequency	(%)	Mean± SD
Sodium Level					2018.66± 1187.84
	< 1200 mg	Normal	12	23.08
	1200- 2000 mg	Moderate	18	34.62
	> 2000 mg	severe	22	42.30
Knee Joint Pain	1_3	Mild	6	11.54
	4_6	Moderate	19	36.54
	7_9	Severe	27	51.92

Based on the data in table 3, a summary of the data on the average level of sodium on knee joint pain was made. The results can be seen in table 4.

Table 4. Average Sodium Levels on Knee Joint Pain

Characteristics	Score
Average Sodium Levels (mg)	1594.66	2047.98	2092.26
Knee Joint Pain	mild	moderate	severe

After collecting and calculating the data, statistical analysis was carried out using PLS. The results of the PLS data were to determine the relationship and influence between sodium levels and knee joint pain and biopsychosocial factors. PLS analysis data is seen in table 5.

Table 5. Correlation of Sodium Levels and Knee Joint Pain with Biopsychosocial Factors

	Sodium	Knee Joint Pain
Age	0.411	0.954
Gender	0.046*	0.169
Body Mass Index	0.489	0.044*
Education	0.820	0.354
Occupation	0.623	0.468
Sodium	-	0.024*

^*Indicates significant (p < 0.05)

DISCUSSION:

OA patients who attended the hospital were dominated by women as many as 84.82%. Women experience OA more often supported by pre-elderly age (≥ 46 years)^37,38,39 so that many have experienced menopause. OA is a degenerative and chronic disease.⁴⁰Increasing age with an unfavorable lifestyle will cause OA. The function and strength of the body in the elderly have been reduced.

Menopausal women’s have minimal Estrogen which causes decreased absorption of Calcium. Calcium is the matrix of bone formation. Decreased calcium as a risk factor for osteomalacia and osteoporosis.⁴¹ Osteoporosis causes reduced bone strength.^20,42 Bones become easily fractured and the knee joint burden increases due to body weight.⁴³ This will further increase pain if the muscles and ligaments around the bones are no longer strong due to age.

Joint load can also be caused by overweight and obesity.^18,38,39 BMI data in the study subjects were found to be overweight (42.31%) and obese (30.77%). This condition causes knee joint pain during activities. The risk of developing OA is two times greater in overweight people than in the normal weight group. In addition, seen from radiological changes, obesity is a predictor of progressive disability.

Indonesian women get used to preparing their own food at home. The sense of taste will decrease, especially for salty tastes with age. This causes the use of sodium salt to increase to give a savory taste to dishes. So far, people know that an increase in sodium in the body can cause heart problems and strokes.⁴⁴ However, sodium that is coagulated in the body cannot be directly excreted through urine or sweat. Coagulated sodium can enter sodium channels and persist for up to 10 days.⁴⁵Sodium channels are also present in joints and there is an increase in IL-17 as a marker of OA. The women subjects also work as employees with minimal time at home. This makes it possible to prefer instant food ingredients for cooking. All instant foods contain a high sodium level. The content of sodium salt added in the processing of instant food is 10 times greater than the sodium salt added in the home processing process.⁴⁶

In addition, the number of subjects who work also as a pain trigger⁴³ even though in statistical analysis it does not affect sodium levels and knee joint pain. Most of the work done by research subjects was as an entrepreneur (36.54%). An entrepreneur needs more time and activities so they pays less attention to their diet or rest patterns. This can increase the incidence of joint pain and increase sodium salt intake indirect

Pain is divided into several categories, namely non-neurogenic neuromusculoskeletal pain, neurogenic musculoskeletal pain and radicular pain. Most cases of OA are classified as non-neurogenic and neurogenic neuromusculoskeletal pain so that the therapy given uses paracetamol, NSAIDs and neuroleptic groups. The management of OA therapy has been regulated by OARSI (Osteoarthritis Research Society International) and IRA, both pharmacological and non-pharmacological therapy. ^1,47 The most commonly used pharmacological therapy for OA is the Nonsteroid Antiinflamation Drug’s (NSAID) group. This class of drugs only treats the symptoms of the disease without reducing the cause of the pain. NSAIDs can also be used for other arthritis such as Rheumatoid Arthritis (RA).⁴⁸ The use of supplements such as glucosamine is also used as a therapy for OA, although it is still under debate.⁴⁹ OA therapy can also be done by low impact exercise and physiotherapy ^50,51,52 but this method takes a long time to provide effective results. The Prolonged OA pain must be faced patiently and calmly because stress will increase arthritis pain.⁵³ In addition to the above therapies, the use of topical therapy in the form of gels and creams is also recommended to treat pain in OA.⁵⁴

In table 3 it was shown that the average sodium level of OA patients through food intake is 2018.66 mg. This value was above the normal standard of the Regulation of the Minister of Health of the Republic of Indonesia in 2019 which was 1100-1300 mg (men) and 1200-1400 mg (women) for ages 50-80 years. Meanwhile, all study subjects experienced mild, moderate and severe knee joint pain. Table 4 provides an explanation that all categories of knee joint pain in OA patients have an average sodium level above normal. Sodium is one of the risk factors for OA through the IL-17 secretion. Increased sodium levels as one of the factors causing OA need to be a concern in non-pharmacological therapy. It can also help reduce and stop the increase in knee joint pain.

CONCLUSION:

In this study, it can be concluded that high sodium levels in OA patients cause an increase in knee joint pain. There needs to be an education given to OA patients as non-pharmacological therapy to reduce sodium salt intake.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The authors would like to thank Department of Orthopedics and Traumatology, Level III Brawijaya Hospital, Surabaya, Indonesia for their kind support during research.

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Received on 20.10.2021 Modified on 28.01.2022

Research J. Pharm. and Tech 2023; 16(1):323-327.

DOI: 10.52711/0974-360X.2023.00057