What dietary plan should be recommended for a 72‑year‑old woman with polymyalgia rheumatica who is about to start prednisone therapy?

Dietary Management for Polymyalgia Rheumatica on Prednisone Therapy

A 72-year-old woman starting prednisone for PMR requires a comprehensive dietary strategy focused on preventing glucocorticoid-induced osteoporosis, managing cardiovascular risk, and controlling blood glucose—these interventions directly reduce morbidity from long-term steroid therapy.

Calcium and Vitamin D Supplementation (Highest Priority)

All patients starting prednisone therapy should immediately begin calcium and vitamin D supplementation to prevent glucocorticoid-induced bone loss. 1

• Calcium supplementation is recommended as first-line therapy for any patient anticipated to receive at least 5 mg prednisone equivalent for 3 months or longer 1
• Vitamin D supplementation should be initiated concurrently with calcium 1
• This intervention is critical because even low-dose prednisone (mean 6 mg/day) causes significant bone loss: 2.6% at lumbar spine, 2.9% at femoral neck, and 4.3% at the trochanter over 14 months 2
• Bone loss occurs rapidly, with total body bone mass decreasing by 50g in the first 6 months of therapy 2
• The bone loss correlates directly with cumulative prednisone dose, particularly at trabecular-rich regions 2

Dietary Sodium Restriction

Limit sodium intake to minimize fluid retention and hypertension risk associated with glucocorticoid therapy. 1

• Prednisone causes sodium retention with resultant edema and potassium loss 1
• This is particularly important for patients with pre-existing hypertension or congestive heart failure 1
• Sodium restriction helps mitigate one of the most common adverse effects of chronic steroid therapy

Potassium-Rich Foods

Increase dietary potassium through foods like bananas, oranges, potatoes, and leafy greens to counteract glucocorticoid-induced potassium loss. 1

• Corticosteroids cause potassium depletion through mineralocorticoid effects 1
• Adequate potassium intake helps prevent hypokalemia and associated complications

Blood Glucose Management

Adopt a low glycemic index diet to minimize risk of steroid-induced hyperglycemia and diabetes. 3

• Diabetes is identified as a relevant comorbidity that increases risk of glucocorticoid-related adverse events 3
• Patients with diabetes or glucose intolerance require careful monitoring during steroid therapy 3
• Dietary carbohydrate control becomes essential for preventing or managing steroid-induced hyperglycemia

Protein Intake

Ensure adequate protein intake (1.0-1.2 g/kg body weight daily) to counteract glucocorticoid-induced protein catabolism and muscle loss. 1

• Corticosteroids increase protein catabolism, reducing the protein matrix of bone 1
• Adequate protein supports muscle strength maintenance—important since muscle strength can increase by 20-60% with proper PMR treatment 2
• This helps prevent sarcopenia and maintains functional capacity

Weight-Bearing Exercise and Lifestyle Modifications

Engage in weight-bearing exercise for 30-60 minutes daily as part of an individually tailored exercise program. 1, 3

• Weight-bearing exercise is a suitable first-line therapy for reducing adverse bone effects 1
• Patients should have access to advice on individually tailored exercise programs 3
• Lifestyle modifications should include cigarette smoking cessation and limitation of alcohol consumption 1

Cardiovascular Risk Factor Management

Monitor and manage cardiovascular risk factors including dyslipidemia through dietary modifications. 4

• Assessment of cardiovascular risk factors and dyslipidemia is recommended for all PMR patients 4
• This includes limiting saturated fats and emphasizing heart-healthy fats (omega-3 fatty acids, monounsaturated fats)
• Cardiovascular disease is a comorbidity associated with increased risk of glucocorticoid-related adverse events 3

Bisphosphonate Consideration

Bisphosphonate therapy (e.g., alendronate, risedronate) should be initiated if bone mineral density is below normal, in addition to dietary calcium and vitamin D. 1

• Current recommendations suggest initiating all interventions in patients anticipated to receive at least 5 mg prednisone equivalent for 3 months 1
• Bisphosphonates are specifically indicated when BMD of lumbar spine and/or hip is below normal 1
• This represents a critical adjunct to dietary calcium and vitamin D for comprehensive bone protection

Monitoring Requirements

Schedule regular follow-up every 4-8 weeks in the first year to assess steroid-related adverse effects including bone health, blood glucose, and blood pressure. 3, 4

• Continuous documentation of steroid-related side effects is essential 3
• Monitor for evidence of osteoporosis, diabetes, hypertension, and other glucocorticoid complications 3
• This allows early intervention if dietary measures prove insufficient

Common Pitfalls to Avoid

• Do not delay calcium and vitamin D supplementation—bone loss begins immediately with steroid initiation 2
• Do not assume low-dose steroids are bone-sparing—even doses below 5 mg/day can cause significant bone loss 2
• Do not neglect cardiovascular risk—glucocorticoids affect multiple metabolic parameters beyond bone health 3, 4
• Do not rely solely on dietary measures—pharmacologic bone protection (bisphosphonates) is often necessary 1