Lupus and Nutrition. Topics for Today Complementary and Alternative Medicine Vitamins A, C, E and D Cardiovascular disease in lupus – Benefits of certain.

Lupus and Nutrition

Topics for Today • Complementary and Alternative Medicine• Vitamins A, C, E and D• Cardiovascular disease in lupus– Benefits of certain diets, omega 3

• Herbal Supplements

Disclaimer: No specific diet for the treatment of SLE exists at this time

• Official recommendations are to eat healthy (fresh fruits, vegetables, whole grains, lean protein) and exercise.

• We have limited human studies • Possible adverse actions on Lupus– Excess calories, fat (saturated) and protein – L-canavanine (found in alfalfa)

• Possible beneficial dietary compounds– Omega 3 (polyunsaturated fatty acids), Vitamin D,

Vitamin A and E, DHEA

Evidence Based Medicine• Grades of evidence

– Case reports– Case series– Case controlled studies– Cohort studies– Randomized controlled trials

• Need to be cautious about products not approved by the FDA or the ACR. Considerations:– What is the proof? Is it effective in lupus?– Is it un-safe?

• Dietary supplements are regulated as foods, not drugs, so there could be quality issues in the manufacturing process

Complementary and Alternative Medicine

• Definition: a set of healthy systems, practices and products that are not generally considered to be part of conventional medicine (http://nccam.nih.gov/health)

• CAM consists of natural products (vitamins, herbs, and supplements), mind and body medicine and other body-based practices, as well as alternative medicinal systems such as traditional Chinese Medicine, Ayurvedic practices and homeopathy.

Usage of CAM is common

• According to National Health Interview Survey nearly 40% of adults in the United States actively use CAM and over 70% will use CAM at some point in their lifetime.

• Most frequently used CAM therapies include natural products, deep breathing and meditation and chiropractic treatment.

• Up to 65% of SLE patients have used CAM

Usage of CAM in SLE

Moore et al. Arthritis and Rheumatism 2000

-In one study of SLE patients in England, Canada and the US up to 65% had used CAM within that year.-Most common form was relaxation techniques -Subjects using CAM were more likely to be younger, attained higher levels of formal education and had shorter disease duration (less than 1.1 years). They also exhibited poorer self rated health status and satisfaction with medical care but had little objective evidence of worse disease on formal disease activity rating scales.

AntecedentsGeneticsDietaryEnvironmentalOccupationalLearnedTraumaticDisease-

inducedDrug-induced

Triggering factorsSusceptibility

Genes

Environmental Factors

Modulating factors

Exogenous or Endogenous

Antigen

ImmuneResponse(cytokine and

effector functions)

ToleranceProtection from

Infection Allergy

Autoimmunity

Nutritional Balance

Energy ProductionOxidative Stress

StructuralNeuroendocrine

functionMind-Body

GI function

Inflammatory function

Functional Medicine Approach

Vitamins A, C, E, D

• Epidemiologic studies examining low intake of vitamin D, C and E have not found a causative role for development of lupus, however there is some evidence to suggest that supplementing these vitamins may help alleviate lupus symptoms

• Vitamin D is an important steroid hormone that has effects on bone health, cardiovascular health and the immune system

• Vitamin D deficiency is common in lupus patients (in some studies has been found to occur in 66% of lupus patients).

• Factors that may contribute to low vitamin D include sun avoidance or medications.

Vitamin D and Lupus

• Some studies have shown that lower vitamin D levels correlate with increased lupus activity.

• One recent placebo controlled trial with 267 lupus patients with low vitamin D did find that supplementation with 2000 IU daily for 12 months did improve lupus disease activity score and decrease in dsDNA antibodies (Abou-Raya et al. J Rheum 2013).

• We do know that vitamin D has potent anti-inflammatory properties and helps suppress immune cells that are involved in autoimmunity.

Bone health and Lupus

• Vitamin D is also an important player in bone health• Osteoporosis (low bone density) is common in lupus patients:• Some studies suggest that osteoporosis is present in over 20% of SLE

patients.• Lupus patients are at risk of developing osteoporosis due to vitamin D

deficiency from sun avoidance, early menopause from drugs that are used in some lupus patients and steroid use.

• Recommend adequate calcium intake (1500 mg daily, 1 glass of mild = 300 mg) and adequate vitamin D (2000 U daily is safe)

Schmajuk et al. Arthritis Care Res July 2010.

The anti-oxidant debate• Oxidative stress has been thought to cause tissue

damage and contribute to cardiovascular disease

• Anti-oxidant vitamins such as vitamin C and E have beneficial effects on cardiovascular health.

• Unclear if these anti-oxidant properties extend to the treatment of lupus.

Vitamin C

• A prospective Japanese study with 241 lupus patients found that a diet rich with vitamin C resulted in less active disease (Minami et al. J Rheum 2003)

Vitamin E

• Study with lupus mice have found beneficial effects with low dose vitamin E supplementation (less than 400 IU/daily) while higher doses resulted in worse disease and shortened life span. (Hsieh and Lin, Nutrition 2005).

• A Hong Kong Study enrolled 39 women with lupus and found no significant vascular improvement with vitamin C (500 mg daily) and high dose vitamin E (800 IU daily) (Tam et al. J Rheum 2005).

• A recent large meta-analysis study (studied 15 RCT trials with 188209 participants) found no beneficial effect with vitamin C and E supplementation on the effect of major cardiovascular event such as heart attack or stroke. (Ye, Li and Yuan. PLoS One 2013).

Vitamin A

• Vitamin A derivatives (retinoic acid) have had beneficial effects in Lupus patients with skin disease ( however very few studies with few patients)

• Some studies suggest improved immune function with vitamin A supplementation

• Caution as too much vitamin A can cause toxicity (Daily recommended amount 5000IU daily)

Cardiovascular Disease and Lupus

• Atherosclerotic heart disease is common in SLE and is the current leading cause of death

• Women with lupus have a 5-6 fold increased risk of cardiovascular disease compared to the general population, this risk is even higher in the younger population (Women aged 35-44 years).

• Lupus patients are more likely to have certain classic risk factors: high blood pressure, diabetes and obesity.

• Lupus also contributes to development of atherosclerosis

Overall survival in lupus has improved

Gabriel S et al Arthritis Rheum 1999;42:46-50

1950-1979 1980-1992

CV dz

• Reduced intake of saturated fat and cholesterol

• Increased physical activity

• Weight control

• Quit Smoking!

Ways to improve cardiovascular disease risk factors without medications

Bruce, Best Practice Res Clin Rheum 19:823, 2005

Omega 3 and Omega 6 poly-unsaturated fatty acids

• Diets high in saturated fats and omega 6 fatty acids contribute to inflammation as they are the pre-cursors for pro-inflammatory compounds

• Omega 3 poly-unsaturated fats are the pre-cursors for anti-inflammatory compounds

• Omega 3 Poly-unsaturated fatty acids have cardio-protective effects and may help prevent cardiovascular disease

• Lupus mice fed high saturated fat and high omega 6 diets have more severe disease and earlier mortality

Fish Oil is high in Omega 3 fatty acids

• Fish oil supplementation in mice with lupus helps prevent progression of disease

• Fish oil supplementation in lupus patient has been studied: – One prospective study found improvement in disease activity

scores after supplementing with 3000mg of fish oil daily for 6 months (Wright et al. Ann Rheum Dis 2007).

– However more recent study found no change in disease activity with supplementation over 3 months and actually found higher levels of LDL (bad cholesterol) in the treatment group. (Bello et al. Rheum Int 2013). ? Treatment duration effect?

– One small uncontrolled trial with 9 lupus patients with kidney disease did find small level of improvement in kidney function (Clark et al. J Coll Nutrition 2001)

Mediterranean Diet

• Heart Healthy, with

good balance between omega 3 and omega 6 fatty acids

• Has been shown to have benefits in patients with rheumatoid arthritis with improvement in arthritic symptoms

• Not studied in SLE patients

Foods rich in Omega 3 Fatty Acids

• Flax Seeds, walnuts, pumpkin seeds• Fatty fish: salmon, tuna, halibut• Soy and Tofu• Green Leafy Vegetables (kale, spinach, parsley,

mint, brussel sprouts)• Canola Oil, Flaxseed oil, soybean oil • Certain eggs are fortified with omega 3s

Herbal Remedies

• Herbals used for arthritis pain• Evening Primrose Oil: Contains an unsaturated fatty acid with anti

inflammatory properties. Potential side effect: should be used in caution if seizure history

• Devils Claw: potential side effects: GI upset, ulcers, bleeding• Tulsi (holy basil): thought to have antimalarial, analgesic and anti-

inflammatory properties. Should not used in pregnant women as it can cause uterine contractions

• Willow Tree: used since ancient times for pain relief. Contains salicylates. Can interfere with blood thinners, liver and kidney disease-use with caution

• Thunder God Vine: ancient chinese herbal remedy for pain and inflammation. Few studies with lupus patients showing benefit. Side effects include GI upset and infertility

Turmeric

• Curcumin has been found to have anti-inflammatory properties

• Recent study with 24 lupus patients with kidney disease found significantly improved kidney function in the patients given 1500 mg turmeric capsules daily. Difficult to interpret as the study only had 12 patients in each arm. (Khajehdehi et al. J Ren Nutrition 2012)

• Warning: interacts with blood thinners, may increase risk of bleeding

DHEA• Not a nutrient or dietary supplement• Is a naturally occurring adrenal steroid that is a precursor for

other steroid hormones such as estrogens and androgens. • Sold as over the counter supplements• Levels of DHEA are lower in lupus patients • Several studies have examined the role of DHEA supplementation

in lupus patients with mixed results• A large RCT with 381 lupus patients randomized to DHEA 200 mg

daily supplement or placebo for 1 year found improvement in overall disease activity (59% vs 45%) with DHEA supplementation ( Petri et al. Arthritis Rheum 2004)

• Acne and hirsutism were most common side effects

Recommended Daily AmountsUS Recommended Daily AmountsRecommended Dose Maximum Dose

Vitamin A 3000 IU 10,000IU

Vitamin C 75 mg daily 2000 mg daily

Vitamin E 33 IU daily 1100 U daily

Vitamin D 600 IU daily 4000 IU daily

Calcium 1000-1200 mg daily 2500 mg daily

Possible beneficial substances in treatment of SLE

Beneficial Substances Recommended dose based on studies (not official recommendations)

DHEA 200 mg daily

Turmeric 1500 mg daily

Omega 3 Fish Oil 3000 mg daily

Vitamin E 400 U daily

Vitamin A 5000 IU daily

Vitamin C 500 mg daily

Do no harm!

Examples of potentially harmful use of CAM:

• Many herbs can interfere with prescription drugs, or can be dangerous if taken in large quantities. Always check with your doctor before taking any herbal remedy or dietary supplement.– Some herbs contain undeclared pharmaceutical compounds- such as

non-steroidal anti-inflammatories– Some contain estrogenic activity– Beware of ‘stimulants of the immune system’

• Use of unproven remedies as a substitute for conventional therapy

• Supplements can interact with prescribed or over-the-counter medicines, and other supplements

• "Natural" does not necessarily mean "safe" or "effective." Overall, there is not much rigorous research available on the effectiveness and safety of botanical and other supplements

Do no harm!

General recommendations on nutrition• Healthy well-balanced diet is advisable for general

health, cardiovascular health, and possibly lupus specifically. – Data for omega-3-fatty acids

• WHAT YOU CAN DO-

lifestyle modification to decrease risk of CV disease

• Basic MVI with daily recommended amounts of vitamins is reasonable– Exception to this is that vitamin D may require extra

supplementation