Nutrition and Lupus

by Tammy O. Utset, M.D., M.P.H.
Associate Professor of Medicine, University of Chicago
 
Nutritional issues in lupus focus on four general areas:  Management of steroid side effects, bone health, heart health and micronutrient intake.
 
Management of Steroid Side Effects
 
Many lupus patients will require the use of steroids (prednisone, medrol) on a chronic or intermittent basis to control disease activity, and the side effects of these drugs are quite predictable.  There is a tendency toward weight gain especially affecting the face, neck, upper back and abdomen.  Cholesterol levels, blood pressure and blood sugar levels may go up as well.  Nutrition issues should focus on controlling caloric intake to minimize weight gain, while maintaining a balanced diet.  Fad diets lacking in carbohydrates or adequate protein intake can be dangerous in the setting of medical disease such as lupus.  Because one’s appetite is increased by steroids, conscious strategies to avoid overeating should be considered.  It is helpful to fill the house with low calorie snack such as vegetables and fruit, and try not to temp fate by having high calorie food available, if practical based on family situation.  Purchase of food types for family members which the patient herself/himself happens to dislike is another strategy to resist temptation in the home environment.  Referral to a trained dietician may be helpful.  Although not formally studied, if there is no kidney involvement, a high protein diet and strength training program could be considered to minimize weight gain and muscle loss in highly motivated lupus patients on steroid therapy.  The appropriateness of such a program should be discussed with your physician.  Based on abn ormalities in these areas, specific dietary changes to help with these problems may be needed.
 
Bone Health
 
Bone damage can occur in lupus in two ways, osteoporosis and (more rarely) avascular necrosis.  Osteoporosis is a much more common problem, and refers to thinning of the bone gradually over time.  Some thinning occurs as a normal part of aging, but it is much more marked, severe and early if one has to take steroids on a chronic or frequent basis.  Cigarette, Caucasian or Asian Race, and Low body weight are other risk factors.  It is important to be sure to get adequate calcium either by dietary intake or by calcium supplements.  Guideline for calcium intake is based on whether you are on or off steroids and whether you are in menopause or not:
 
BEFORE MENOPAUSE, NOT STEROIDS:
Calcium 1000 mg/day
 
BEFORE MENOPAUSE, ON STEROIDS:
Calcium 1200-1500 mg/day
 
AFTER MENOPAUSE, ON OR OFF STEROIDS:
Calcium 1500 mg/day
 
Vitamin D is needed in order to properly absorb and use calcium, and deficiency in vitamin D is very common in lupus, particularly in lupus patients who are sun-sensitive and strictly avoid the sun.  It is best to take a calcium supplement with vitamin D added, and the daily intake of vitamin D should generally be 800 IU/day rather than the standard 400 IU/day.  If you calcium supplement only has 400 IU vitamin D, taking a regular multivitamin will often bring up the total vitamin D to the target 800 IU.  Along with adequate calcium and vitamin D, regular exercise can stimulate bone to build strength.  Finally, prescription medications can be used to prevent or treat osteoporosis. 
 
Heart Health
 
Lupus patients are prone to premature heart disease, and it is important to carefully control all the standard risk factors for heart disease.  That means getting cholesterol checks, and treating high cholesterol, high blood pressure or diabetes rigorously if you have these problems.  There is some data to suggest that fish oil, which is thought to be good for the heart, may have anti-inflammatory effects for lupus as well.  However, that is only true if saturated fat and cholesterol is cut out of the diet as well.  Thus, following a low cholesterol diet, excluding most red meat and butter, and adding some fish such as salmon or tuna (or taking fish oil supplements) may be of some benefits for both your heart and your lupus.  Some lupus patients feel a vegetarian diet is beneficial (which is also heart-healthy), but adequate medical studies and the impact of vegetarian diet on lupus are lacking.  If you do follow a vegetarian diet, it is important to take a vitamin B12 supplement and be sure to get enough protein, since steroid therapy can already cause muscle atrophy.
 
Micronutrients
 
There is no consistent data on Micronutrient therapy or deficiencies in lupus.  One study found antioxidants in general (including vitamin A, beta-carotene, vitamin C) to be lower in lupus patients than in healthy controls, but this might be the consequence of inflammation rather than a cause.  Another study found lower vitamin C intake to correlate with higher disease activity in lupus, but this is not proof that vitamin C affects lupus activity.  In the 1980s there was some interest in selenium supplementation improving lupus in mouse models, but there have been no good human studies to support selenium supplementation in lupus.  Thus currently there are no standard medical recommendations for micronutrient supplementation in lupus.  A standard daily multivitamin, or a multivitamin with extra antioxidants, is probably a good idea for lupus patients, where appetite or food intake may be sporadic.