Description:

One of the ways the human immune system shields the body against invading foreign particles such as bacteria and viruses (antigens) is by producing rebellious substances called antibodies. When an antigen arrives at the doorstep of specialized B cells, the cells react by dispatching antibodies to fight against the intruders. However, in patients with lupus, a chronic autoimmune disease, the immune system misidentifies its own tissues as antigens and therefore produces antibodies that "attack" its own body tissues, stimulating a false-alarm inflammatory cascade. This renegade process can cause a wide variety of symptoms that are sometimes harmless, such as skin rashes, but it can also lead to tissue damage and serious, even life-threatening, complications if left untreated. Yet with medical treatment and careful nutritional monitoring, individuals with lupus can mitigate flare-ups and lengthen remissions (disease-free periods). In the 1950s, there was only a 50% survival rate for those suffering from this illness after 4 years, whereas today that figure is more than 97%.

Types of Lupus:

There are three types of lupus:

• Systemic Lupus Erythematosus (SLE), which affects multiple organs in the body and is the most common type of lupus. This disease originally got its name based on the typical butterfly-shaped rash that some lupus patients get across their cheeks and the bridge of the nose. The scientist who named the disease deemed the rash resembled a wolf bite, thus the Latin name "lupus" for wolf and "erythema" for the red color of the rash. The word "systemic" was added when it became apparent that lupus could affect almost all the organs of the human body.
• Discoid Lupus. Patients with this disease have only skin-related problems, such as rashes that usually appear on the face, but may also appear on the neck or even the scalp.
• Drug-Induced Lupus is the third and least prevalent type of lupus. About 4% of patients taking certain drugs, such as procainamide and hydralazine, have been shown to develop autoimmune antibodies and only a small number of these actually suffer from lupus-like symptoms that usually disappear when the medication is stopped.

Symptoms:

There is a wide range of symptoms associated with lupus and no one lupus patient will have them all. The more common ones (in order) include joint pain and swelling, fever, fatigue, skin rashes, anemia, kidney problems, chest pain, (due to inflammation of the lining of the heart/lungs), sensitivity to light/sun, hair loss, Raynaud-type symptoms (cold sensitivity in fingers and toes), seizures and oral/nasal sores. Other symptoms include muscle aches, depression and even episodes of psychotic behavior. The disease and treatment can lead to more serious complications such as kidney problems, arthritis, diabetes and hypertension.

Since lupus is a disease with such a wide variety of symptoms and can be difficult to diagnose, in 1982 the American College of Rheumatology developed a list of eleven criteria for diagnosing SLE. The 1997 updated list is presented below. A patient must have at least four of the following criteria to be considered a possible lupus sufferer.

Eleven Criteria for Diagnosing SLE:

• Butterfly shaped rash over nose and cheeks
• Discoid rash (round spots on various parts of the body)
• Sensitivity to sun or light in general
• Oral or nasal ulcers
• Arthritis, nonerosive
• Inflammation of the lining of the lungs (pleuritis) or heart (pericarditis)
• Kidney problems including protein loss in the urine greater than 0.5grams per day or the presence of other abnormal elements
• Seizures or psychosis
• Hematologic (blood) problems which include one of the following: low lymphocyte count (lymphopenia), low white blood cell count (leukopenia), antibodies to red blood cells (hemolytic anemia) and low platelet number (thrombocytopenia)
• Immunologic problems indicated by one of the following blood tests: positive finding for anti-phospholipid antibodies, anti-DNA antibodies or anti-Sm antibodies
• A positive ANA (antinuclear antibody) blood test (when the body produces antibodies against its own cell nuclei).

Prevalence and Incidence:

Obtaining accurate data on the prevalence (number of diagnosed cases) and incidence (number of new cases) of lupus is difficult. Although several surveys have been conducted, unfortunately they use disparate methods that vary from relying on hospital records/databases to conducting phone surveys. Some studies count only definite cases and others include probable lupus cases in the final numbers. Age, gender and race must be taken into account as lupus affects various populations differently. Studies have shown disease rates to be higher in African Americans, Hispanics, and some Asian and Native American populations. An overview of several studies reported that the overall prevalence of SLE ranges from 12 to 51 cases per 100,000, while incidence varies from 2 to 8 per 100,000. A study conducted by the Lupus Foundation of America in 1994 showed that between 1,400,000 and 2,000,000 Americans had been diagnosed with lupus. More recently published information puts the numbers as high as 2,500,000. Even though the disease can develop at any age in both men and women, it primarily affects women (almost 90% of lupus sufferers are female), though male/female differences are mainly found in the age group 15-64 years. SLE usually develops somewhere between the late teens and mid-forties. The higher number of female lupus patients may be due to hormonal factors.

Cause:

The cause of lupus is unknown, but may be due to genetic and environmental factors such as viruses, certain drugs, sunlight, or stress. Even though genetics may be involved, only approximately 5% of children of lupus sufferers will develop the illness and only 10% of patients have a parent or sibling who has the disease. For those who have lupus, flare-ups can be triggered by exposure to the sun or light, viral or bacterial infections, physical (fatigue, cold, injury, surgery, etc.) or emotional stress, medications, pregnancy, birth control pills/hormone replacement therapy and sometimes only a change in weather or season. There is no cure for lupus; however, flare-ups can usually be controlled with medications. For those that are light sensitive, use of sunscreen and protective clothing can minimize problems.

Treatment:

The most common medications used in the treatment of lupus include:

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin, Advil and Naprosyn used for arthritis symptoms;
• Corticosteroids , such as prednisone, which serve as anti-inflammatory agents and immune system suppressors that can have several negative side effects including weight gain, osteoporosis, high blood pressure, diabetes and increased risk of infection;
• Anti-malarials for skin and joint problems;
• Cytotoxic or Immunosuppressive drugs (used as a last resort) which have both anti-inflammatory as well as anti-immune effects. Side effects include low white blood cell count, anemia, and increased risk of infection and cancer.

Lupus patients should follow a generally healthy lifestyle that includes getting plenty of sleep, eating a healthy diet (see nutritional information below), exercise (swimming for those with arthritis) and not smoking. Relaxation techniques and support groups can also be extremely helpful when dealing with a chronic disease.

Nutritional Recommendations:

Those with lupus should obviously avoid any foods that trigger flare-ups. Patients should follow a healthy diet that is low in fat, especially saturated fat, and high in whole grains, fruits and vegetables, ensuring an adequate fiber intake. Excessive caffeine consumption should be avoided as it can interfere with calcium absorption. When lupus symptoms flare-up, some patients lose their appetites and thus should consume fortified foods or take a daily multivitamin/mineral supplement.

For those patients not taking cytotoxic drugs, some doctors recommend a daily dose of the following antioxidants:

• Vitamin C , 500mg, found in citrus fruits, raw leafy vegetables, tomatoes, strawberries, cantaloupe, cabbage and green peppers;
• Vitamin E , 400 IU, found in wheat germ, corn, soybean and sunflower oils and avocados. Patients who are taking anticoagulant drugs should check with their doctors before consuming supplemental vitamin E;
• Mixed beta-carotenes , 15,000 IU, found in dark green leafy and yellow-orange vegetables and fruits;
• Selenium , 150 mcg, found in brazil nuts, seafood and poultry.

LifeSpring recommends these levels. Though some of these levels are above the recommended daily allowances (RDA), they are well within the range of maximum safety levels. LifeSpring offers number of meals, soups and snacks that are rich antioxidants vitamin C, E, mixed carotenes and selenium. Here are some selections: Tortellini Minestrone Soup, Creamy Chicken Soup, Minestrone Soup, Pinto Bean Soup, Caribbean Black Bean Soup, Black Bean Chile with rice, Meatloaf with mashed potatoes, Sweet & Sour Chicken Chow Mein, Chicken Alfredo, Salmon Ravioli, Italian Sausage and Pasta, Seafood Gumbo, Creole Cod, Italian Chicken and Pasta, Spoonable Smoothies (Chocolate, Strawberry Banana, Mango Orange), and Bakeshop Cookies (Oatmeal Raisin and Chocolate Fudge).

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Alcohol consumption should be limited for several reasons as alcohol can have an adverse affect on certain medications, can increase stomach problems for those patients taking NSAIDs and causes an increase risk for developing certain cancers.

Health Consequences of Disease/Medications:

The medications that lupus patients must take can cause side effects, such as those listed below, with both nutritional and health consequences.

• Weight Gain:  Corticosteroids can cause weight gain due to an increase in appetite. If a lupus patient is just starting to take corticosteroids, they should be especially careful with their diet to avoid gaining weight. For patients who are already on this medication and have already gained weight, a balanced diet that is lower in calories and low in fat, along with an exercise program, will help them shed the extra pounds.
• High Blood Pressure/Fluid Retention:  Corticosteroids can cause high blood pressure and fluid retention, which can be reduced by decreasing consumption of sodium and lowering excess body weight. Many processed foods are high in sodium so check nutrition labels, especially canned foods. Sodium intake should be limited to 2,400 mg per day.
• Osteoporosis:  Corticosteroids can also cause osteoporosis. To counteract this, lupus patients should make sure they consume enough calcium and vitamin D. Natural sources of calcium include milk products (choose low fat varieties), dark green leafy vegetables, broccoli, soybeans and fortified foods. The recommended daily dose of calcium is 1,500 mg. Natural sources of vitamin D are fortified milk and fatty fish. Exposure to sunlight is also a source, though this method may not be available to lupus patients that are highly photosensitive. The daily recommended dose for vitamin D is 400IU per day.
• Diabetes:  Long term use of corticosteroids can also cause diabetes, requiring adherence to a special diet.
• High Cholesterol:  Corticosteroids can also cause lupus patients to have higher serum cholesterol levels and put them at risk for developing cardiovascular disease. Patients should adopt a low fat/low cholesterol diet. The National Cholesterol Education Program (NCEP) issued dietary guidelines for people with high serum cholesterol that recommend no more than 30% of calories from fat (not to exceed 7% from saturated fat) and less than 200mg of dietary cholesterol per day. Intake of saturated fats (and the equally harmful trans-fatty acids) can be reduced by consuming less butter and margarine and increasing consumption of monounsaturated fats found in olive and canola oils.
• Kidney Disease:  Many lupus patients suffer from kidney disease. Depending on the nature of the problem, patients may be placed on a low protein or low salt diet to reduce fluid retention and high blood pressure that may result from kidney disease.
• Anemia:  Fortified foods or iron supplements may be recommended if patients develop lupus-related anemia.
• High Homocysteine:  Some lupus patients have higher than average levels of homocysteine in their blood that may be linked to an increased risk of heart disease. A study funded by the Arthritis Foundation found that daily vitamin B₆ supplements decreased blood levels of homocysteine in patients with lupus. Natural sources of vitamin B₆ include liver, whole-grain cereals, legumes, potatoes, bananas and oatmeal. Consumption of folic acid (400 micrograms)found) found in liver, kidney beans, dark green leafy vegetables, asparagus, broccoli and fortified foods is also recommended for patients with higher blood levels of homocysteine. Supplemental folic acid may be necessary to achieve the recommended dosage, though older patients and vegetarians should make sure they consume enough vitamin B₁₂, as folic acid can mask a B₁₂ deficiency.

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Possible Nutritional Therapies:

Omega-3 Fatty Acids: The omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) typically found in fatty fish such as salmon, albacore tuna, and sardines, as well as in flaxseed meal, have been shown in some studies to have anti-inflammatory properties without the side effects of some lupus medications. Fish oil capsules are also available as a dietary supplement. Flaxseed can be bought whole and ground at home in a coffee grinder. Flaxseed oil is not recommended, as it can quickly become rancid.

Although several animal studies have shown the benefits of taking omega-3 fatty acids in lupus models, there have been very few clinical trials. However, many experts think the addition of omega-3 fatty acids to the diet of lupus patients may allow them to reduce the level of medication they are taking and in a few cases may replace the medication all together. Even though not all doctors are in agreement regarding the benefits of omega-3 fatty acids, the American Lupus Foundation does recommend consuming them albeit not enough research has been done in humans to be able to recommend a daily dose. The best way to add these fatty acids is to consume fish at least three times a week.

Another type of fatty acid that is recommended to lupus sufferers by some doctors as an anti-inflammatory is GLA or gamma linolenic acid; difficult to obtain in a normal diet but foundbut found in the dietary supplements evening primrose oil or black current oil.

Patients Might Want to Avoid:

• Alfalfa.  Many doctors as well as the American Lupus Foundation recommend that patients not consume alfalfa sprouts as they can cause flare-ups or worsen symptoms. Alfalfa sprouts contain the amino acid l-canavanine, present in other foods in small amounts, but especially high in alfalfa. This amino acid has been shown to cause lupus-like symptoms in monkeys. Many herbal supplements contain traces of alfalfa so patients should carefully check labels. For patients who do not want to give up sprouts, broccoli sprouts are a delicious alternative.
• DHEA. stands for dehydroepiandrosterone, a male hormone. Dietary supplements of DHEA are made from extracts of wild Mexican yam. Although many doctors advise against taking these supplements because FDA banned sale of DHEA as an over-the-counter drug in 1985, in 1994, under new laws, DHEA can be sold as a dietary supplement and does not require the FDA approval. Some studies have shown that lupus patients consuming DHEA were able to reduce their intakintake corticosteroids. However, even though DHEA is a supplement that can be bought without a prescription, most doctors advise patients against self-medicating. Side effects include possible masculinization and menstrual problems in women and aggravation of prostate enlargement or even prostate cancer in men. Though DHEA may one day prove to be useful to lupus patients, there are too many unanswered questions to recommend taking this hormone at the present time.
• Aspartame.  News has been circulating in alternative medicine circles and on the Internet linking the use of aspartame, an artificial sweetener, with developing lupus. The Arthritis Foundation says the findings are inaccurate and that their experts have found no scientific evidence to support this claim. Nonetheless, lupus patients should investigate possible negative connections between their illness and the use of aspartame.

Lupus is a disease that must be closely monitored by both patient and doctor. Any nutrition recommendations contained in this article should be discussed with the patient’s physician and preferably a dietitian.

Lupus Foundation of America
www.lupus.org
tel. 800-558-0121 or 301-670-9292

Arthritis Foundation
www.arthritis.org
tel. 404-872-7100

American College of Rheumatology
www.rheumatology.org
tel. 404-633-3777

American Dietetic Association
www.eatright.org
tel. 312-899-0040

Sources for this article:

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Nutrition chapter written by Dr. Peter H. Schur.Blau, S. P. & Schultz, D. Living with Lupus. Perseus Books, Reading, MA, 1993.

Carper, J. Food – Your Miracle Medicine. Harper-Collins Publishers, New York, NY, 1993.

Dibner, R. & Colman, C. The Lupus Handbook for Women. Simon & Schuster, New York, NY, 1994.

Editors of Prevention Health Books. Prevention’s Healing with Vitamins. Rodale Press,Inc., Emmaus, PA, 1996.

Editors of Prevention Health Books. Prevention’s New Foods for Healing. Rodale Press, Inc., Emmaus, PA, 1998.

Hearthholmes, M., Baethge, BA, Broadwell, L, Wolf, RE. Dietary Treatment of Hyperlipidemia in Patients with Systemic Lupus Erythematosus. Journal of Rheumatology 22(3):450-454, 1995.

Horowitz, M. & Brill, M.A. Living with Lupus – A Comprehensive Guide to Understanding and Controlling Lupus while Getting on with Your Life. Nal-Dutton, Bergenfield, NJ, 1994.

Dr. Horowitz is a private rheumatologist in New York.

Lahita, R.G. Systemic Lupus Erythematosus. Academic Press, New York, 1999.

Lahita, R.G. & Philips, R.H. Lupus – Everything You Need to Know. Avery Publishing Group, Garden City Park, NY, 1998.

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Wallace, DJ. The Lupus Book. Oxford University Press, New York, NY, 1995.

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Online sources:

American College of Rheumatology. Fact Sheet on SLE. November, 1999. www.rheumatology.org/patients/factsheet/sle

American Lupus Foundation. Information on Lupus. November, 1999. www.lupus.org/info/

Arthritis Foundation. Aspartame and Lupus. November, 1999. www.arthritis.org/resource/statements/aspartame%5Fand%5Flupus.asp

Arthritis Foundation. Exploration: Medicinal Oils. Arthritis Today, July-August, 1999. www.arthritis.org/at/archive/1999/07%5F08/explorations.asp

Arthritis Foundation. Lupus. Arthritis Today, September-October, 1998. www.arthritis.org/at/archive/1998/09%5F10/rs/lupus.asp

Ask Dr. Weil. Better Methods for Treating Lupus. September, 1996. www.pathfinder.com/drweil/qa_answer/0,3189,76,00

Ask Dr. Weil. Unhealthy Health Food. May, 1998. www.pathfinder.com/drweil/qa_print/0,3008,1235,00

Ask Dr. Weil. Getting Enough Folic Acid? January, 1997. www.pathfinder.com/drweil/qa_answer/0,3189,164,00

Horstman, J. DHEA. Arthritis Foundation - Arthritis Today, January-February, 1999. www.arthritis.org/at/archive/1999/01%5F02/dhea.asp

Mayo Clinic Health Letter, Lupus: Improved Prognosis, but Still Difficult to Diagnose. December, 1997. www.mayohealth.org/mayo/9605/htm/lupus_new

National Institutes of Health. Patient Information Sheet #9, Nutrition and Lupus. November, 1999. www.nih.gov/niams/healthinfo/lupusguide/chppis9