January 15, 2016
By Laura Corrales-Diaz Pomatto and Swamy Venuturupalli, MD
This is a topic that I am very passionate about. Among the numerous patients with severe lupus that I have treated, I have found that those patients who are attentive to their nutrition tend to do better. The exact reasons have not been established as fact, but studies suggest that women with SLE have inadequate calcium intake, low consumption of fruits and vegetables and a high intake of unhealthy saturated fats, which may lead to increased inflammation. While a detailed review of the evidence for or against various dietary approaches to reducing inflammation is beyond the scope of this article, there appear to be some trends towards understanding what kinds of diets may be associated with lowering inflammation. Such diets are called anti-inflammatory diets and these diets generally emphasize plant based ingredients, low to no sugar, low intake of grains especially gluten, omega-3-fatty acids, and lean proteins including low fat dairy. The basic premise of most anti-inflammatory diets is that certain types of foods can either trigger or minimize inflammatory signals within our bodies [1]. Another approach, suggests that caloric restriction or diets low in carbohydrates may decrease SLE-generated fatigue and promote weight-loss [2]. Below, we have summarized the dietary factors that are important for all people suffering from autoimmune diseases, with an emphasis on lupus patients.
The good and bad of fat
Fats are necessary for overall health. Not only is fat an important source of energy, but also for proper organ function, such as the brain. Additionally, fat is necessary for the absorption of Vitamins A,D,E and K in the diet. There are 2 basic dietary forms of fat: saturated (solid at room temperature) or unsaturated (liquid at room temperature). Patients with SLE should limit their consumption of saturated fats as they are already prone to have elevated cholesterol, increased risk for developing dyslipidemia (chronic elevation of fats in the blood), and contributes to inflammation. In contrast, diets rich in unsaturated fats (omega-3’s and 6’s) from plant sources and fish have been linked to lower cholesterol and decreased risk of coronary artery disease. Given that heart disease is 50 times more common in younger SLE patients compared to their peers, managing lipids through diet is exceedingly important.
Dietary Fiber
For individuals with SLE, I recommend they consume foods rich in soluble fibers, with good dietary sources being oats, fruits, and vegetables. The recommended daily intake is 38g for men and 25g for women [3]. Increased fiber consumption is important to help prevent high blood cholesterol, normalize blood sugar levels, and control dyslipidemia. In addition, fiber intake has been inversely associated with SLE disease severity, and studies suggest that this outcome is partly due to the positive interaction between fiber, Vitamin B6 and B12, and folate [4].
Flaxseed is a good source of both fiber and omega-3 fatty acids. More importantly, both human and mouse studies suggest a benefit in SLE symptom management from flaxseed consumption [5].
Dietary grains
Recently, increasing evidence suggests that diets low in grains may dampen inflammation. Some dietary grains such as wheat, rye and barley contain a protein called gluten, which in the gut of some individuals can activate the immune system. By limiting dietary intake of gluten-containing products, individuals with SLE may decrease symptomatic flare-ups [6]. Other diets that promote low carbohydrate intake, including all grains and sugars. These diets promote the consumption of high-fat and moderate protein, while limiting carbohydrate intake. For individuals with lupus, it is not recommended to consume excess fats, nor increase protein consumption beyond minimum amounts, as these individuals are already at a greater risk for kidney damage.
Lupus patients should also be mindful of excess sugar consumption. This is critical as multiple studies suggest individuals with lupus are at a much greater risk for developing glucose intolerance (the inability of cells to uptake glucose from the bloodstream) and Type II Diabetes [7]. As Type II Diabetes is associated with increased inflammation, its development in individuals with SLE may further exacerbate immune flare-ups.
Vitamins in SLE symptom management
Vitamins are necessary organic compounds that our bodies need in small quantities, for proper function.
Vitamin supplementation has been found to be beneficial for symptom management of SLE patients. One study suggested that Vitamin A supplementation may help clear lupus rashes [8]. We recommend that SLE patients should seek to increase their Vitamin A consumption from plant sources, such as carrots, sweet potatoes, spinach, and kale, rather than animal sources, as excess ingestion of Vitamin A from animals has been associated with deleterious side effects.
Increased intake of Vitamin C also appears to be beneficial in SLE symptom management [9, 10]. A good source of Vitamin C is found in citrus, including oranges, papaya, and tangerines. Other studies have shown that increased intake of Vitamin E helps to suppress disease symptoms by decreasing cytokine expression and activity. SLE patients wanting to increase their dietary intake of Vitamin E should consider increasing their consumption of fish, nuts, and whole grain cereal. Although some evidence seems to suggest the beneficial effects from Vitamin D supplementation, it appears to have its greatest effect in those already deficient. Individuals seeking to increase their Vitamin D levels should limit their intake to less than 400IU, as higher amounts are associated with increased risk of strokes and heart attacks [11], and hence, we recommend caution with Vitamin D supplementation.
Calcium
There are many causes for bone loss in lupus including, uncontrolled inflammation, poor absorption of calcium, vitamin D decrease due to lack of sun exposure, and steroid usage which can prevent calcium absorption in the gut. Sufficient intake of dietary calcium is essential for individuals with SLE [12].
To combat bone loss, the American College of Rheumatology recommends people with SLE, who are beginning corticosteroid treatment, should also increase both their calcium and Vitamin D intake, and perform weight-bearing exercises [13]. However, a recent study suggested that calcium supplementation of 1200 mg or greater can be associated with increased risk of strokes and heart attacks [14]. In light of this, we recommend that patients obtain calcium primarily through dietary sources, such as collard greens, fish (primarily sardines), broccoli, and various dairy products and limit calcium supplementation to less than 500 mg.
Not all protein sources are alike
We rely upon dietary protein to supply our bodies with various amino acids to build and repair our tissue. Protein from animal sources are called complete proteins because they contain all the essential amino acids, whereas protein from fruits, vegetables, grains, and seeds may lack an essential amino acid, which can be fulfilled by over-the-counter supplements [15]. For individuals with lupus it is important to consider the type of protein consumed. Although animal-derived protein, specifically red-meat, has a high protein content, it also contains large amounts of saturated fats. Whereas both poultry and fish are low in saturated fats, with fish providing the added benefit of a good source of omega-3 fatty acid [16].
As well, people diagnosed with SLE should be conscious of excess protein intake. Studies conducted in mice and humans found that high protein diets accelerated kidney damage, (when kidney damage had already begun), whereas low protein diets improved survival and immune-function in autoimmune mouse models [17].
The Benefits of Caloric Restriction
Caloric Restriction (CR) has been found to slow the onset of autoimmune diseases and the associated symptoms in various mouse models [18]. CR may help reduce immune cell activation. Additionally, it has often followed for weight loss purposes, though we do not recommend this approach as caloric restriction can be associated with restriction of other important nutrients.
Conclusion
Though the studies are not conclusive, and more work needs to be done in exploring nutritional therapies further, some dietary modifications as noted above make sense for lupus patients. Based on my experience in the treatment management of many lupus patients, a balanced dietary approach can be helpful in managing the severity of lupus symptoms and counteracting side effects of medications.
Summary of Dietary Modifications for patients with autoimmune diseases
| Nutrient | Positive | Negative | Sources |
| Fats | Unsaturated fats omega-3 and omega-6 fatty acids lower low density lipoproteins;
Decrease total cholesterol
|
Saturated fats
Increase low density lipoproteins; Increase in total cholesterol; Increased risk for cardiovascular disease and stroke
|
Unsaturated fats
Fish; olive oil; nuts, avocados, peanut butter Saturated fats Red meats, pork, lard, cream, butter, cheese |
| Vitamin A | Protects against excess cytokine production | High doses can cause headaches, nausea, anemia, and possibly death (primarily derived from animal sources) | Carrots, sweet potatoes, kale, spinach |
| Vitamin E | Decreases inflammation;
Decreases cytokines; Delays disease onset |
N/A |
Whole cereals, nuts, fish, spinach, vegetables |
| Vitamin C | Antioxidant;
Decreases markers of autoimmunity (anti-ds-DNA); Proper immune function |
Too little promotes inflammation | Citrus (oranges, tangerines, grapefruit), papaya broccoli |
| Vitamin D | Proper immune function;
Decreases cytokine production |
Too little leads to poor immune function and bone health;
Too much, increases likelihood of cardiovascular disease |
Fish (salmon, sardines), eggs, and foods fortified with Vitamin D |
| Fiber | Protects against cardiovascular disease;
Lowers blood pressure |
N/A |
Nuts, whole cereals, beans, fruits, and vegetables |
| Calcium | Critical for proper bone function | Excess amounts can promote atherosclerosis and risk for heart disease | Kale, spinach, sardines, soybeans, dairy products |
| Protein | Improved immune function; delay onset of autoimmunity disease | Excess amounts can accelerate kidney damage | Beans, whole cereals, fish, soy, poultry |
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