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Nutrition and Lupus Part 1: Ways to Maintain a Healthy Diet

Adapted from a presentation at the SLE Workshop at Hospital for Special Surgery

Sotiria Everett, MS, RD, CDN, CSSD
Clinical Nutritionist Department of Food and Nutrition Services
Hospital for Special Surgery

Overview

In this presentation, Ms. Everett covers the relationship of diet and nutritional considerations and lupus, osteoporosis, medication side effects, and vitamins and supplements. This is the first of a two-part presentation. In Part II, Ms. Everett will focus more specifically on nutrition and the importance of heart health and kidney health for people with lupus. Before beginning the presentation, Ms. Everett highlighted that nutrition has become an important area of research in regard to lupus.

Lupus and Nutrition

Ms. Everett began by explaining that there is no food that can cause lupus. Lupus is an autoimmune disease, an illness that can affect many body systems. The foods that you eat, however, and the medications you take may have an effect on some of your symptoms. It is also important to understand that there is a link between lupus and osteoporosis and cardiovascular disease. Healthy nutrition can impact on those with these co-occurring diseases. Nutrition (e.g., in the case of osteoporosis, calcium intake) in turn may impact the symptoms and outcomes of these co-occurring illnesses. Here are some key issues and benefits that relate to proper nutrition and people living with lupus;

  • Reduce inflammation (redness and swelling) and other symptoms
  • Prevent nutrient deficiencies
  • Maintain strong bones and muscle
  • Combat side-effects of medications
  • Achieve or maintain desirable weight
  • Reduce risk of heart disease

General Nutrition Guidelines

Ms. Everett then discussed some important general nutrition guidelines of which individuals with lupus should be aware. Some key guidelines include diets low in fat, cholesterol, and sodium; low in refined sugars like soda and concentrated juices; and high in fiber. It is important to be aware of high protein diets which can often stress the kidneys. Most importantly, Ms. Everett stresses the importance of keeping a well-balanced diet.

What foods should be a part of your diet?

Next, Ms. Everett reviewed some of the key foods that are important for your diet. She emphasized that balance is essential – that is, to not eat too much of one thing and not enough of another. Different foods have different nutritional components. Included in the important foods that Ms. Everett highlighted were a variety of fruits and vegetables; foods low in calories and saturated fats; and foods high in antioxidants, fiber, calcium, vitamin D, and Omega 3 fatty acids.

Fruits and Vegetables

When bought fresh, there are no added cholesterol and saturated fats added to fruits and vegetables, and they are low in fat and sodium. Fruits and vegetables contain antioxidants and fiber and are a great source of Vitamin C and Vitamin A.

Healthy ways to add fruits and vegetables into your diet:
  • Snack on fruits and vegetables throughout the day
  • Add vegetables to soups, sandwiches, and salads
  • Add fruit to make smoothes
  • Add fruit to your cereal and yogurt
  • Choose fresh and frozen (without sauces)
  • Go easy on canned foods (choose low salt), dried fruits, and fruit juice

Fats and oils

Healthy Fats (Unsaturated)

Not all fats are unhealthy. Polyunsaturated fats and monounsaturated fats are the healthier fats compared to saturated fats. Some of these fats are high in anti-inflammatory properties and have a rich source of Vitamin E. Foods that contain unsaturated fats include; nuts, seeds, avocados, olive oil, soybean oil, and canola oil. It is important to understand that these fats are still high in calories - therefore, portions should be monitored. These fats, however, are preferred over saturated fats.

Saturated Fats

Saturated fats, on the other hand, can increase inflammation. Some examples of saturated fats are high fat dairy foods (whole milk, half and half, cheeses, butter, and ice cream), fried foods, commercial baked goods, creamed vegetables/soups/sauce, sausages, Italian meats, red meat, animal fat, and processed meat products.

Choose Low Calorie Foods

Avoid drenching your food in dressing, oil, butter, and sugar, which can increase your calorie intake. High calorie foods can cause weight gain and inflammation so it is important to make healthy choices when choosing what foods to eat.

Antioxidants

It remains unproven whether diets high in antioxidants can help with inflammation associated with lupus. Fruits and vegetables are sources of antioxidants such as Vitamin A, Vitamin C, Vitamin E, Selenium, Carotenes, and Bioflavonoids. Later on in the presentation Ms. Everett highlights some key foods that contain these nutrients.

High Calcium and Vitamin D Intake

Foods high in calcium and vitamin D promote healthy bones. Some medications for lupus deplete your body of calcium, so including calcium in your diet is essential.

Grains

Grains are a good source of fiber and energy, foliate, B6, B2, selenium, and zinc, and are naturally low in fat. Some whole grain foods include brown and wild rice, whole wheat bread, whole wheat pasta, rye, oats, quinoa, corn, and barley.

Dairy

Dairy products hold the richest source of calcium and provide a good amount of protein, vitamin D, selenium, B vitamins, and zinc. Foods high in calcium are shown to help build strong teeth and bones, which are very important for lupus patients because of their high risk of osteoporosis.

When choosing dairy products, remember to go either low-fat or fat-free. Some examples include 1% and skim milk, low fat and low sodium yogurt, and low fat cheese. Foods to avoid are 2% and whole milk, which contain a large amount of fat and cholesterol. If you do not or cannot consume milk, choose lactose-free milk, soy milk, and almond milk that are fortified with calcium and Vitamin D. Aim for three or more servings a day.

Meat, Fish, and Poultry

Contain zinc and B vitamins and are a good source of Omega-3 fatty acids and protein to maintain muscle.

Some healthy tips that Ms. Everett spoke about when buying and preparing your meats, fish, and poultry:

  • Red meat is high in cholesterol and saturated fat. Try to limit to once a week if you can.
  • Look for lean meats around 99%.
  • Remove skin from poultry because that is where the most saturated fat is.
  • Cut fat off from red meat.
  • Broil and grill vs. pan fried with oil, deep fried, and breading.
  • It is important to incorporate fish into your diet around 3-4 times a week.
  • Practice portion control - meat should not take up ½ of your plate, it should be more like ¼
  • Best Bets:
    • Chicken breast, lean beef, wild salmon, herring, mackerel, sardines, anchovies, rainbow trout, tuna (canned light), crab, oysters, tilapia, cod, pacific oysters

Omega 3 Fatty Acids

Research indicates that omega 3 fatty acids from fish or fish oils may help manage high triglycerides and heart disease (see references at end of this summary). There have not been any studies, however, that show a reduced disease activity with lupus. Foods rich in omega 3 fatty acids include salmon, sardines, mackerel, bluefish, herring, mullet, tuna, halibut, lake trout, rainbow trout, ground flaxseed, walnuts, pecans, canola oil, walnut oil, and flaxseed oil, and are part of a heart-healthy meal plan.

  • Tips to incorporate Omega 3’s into your diet:
    • Add chopped nuts to salads
    • Add grilled salmon, tuna, and sardines to salad
    • Snack on nuts
    • Sprinkle ground flaxseeds on cereal and yogurt

Beans, Nuts, and Seeds

Good source of vitamin E, selenium, protein, and fiber. Some foods that you can snack on throughout the day include:

  • Brazil nuts
  • Wheat germ
  • Flaxseed
  • Soybeans
  • Kidney beans
  • Tofu
  • Walnuts
  • Lentils

When purchasing, look for beans that are unsalted and low in sodium. When buying canned beans, make sure to rinse and drain excess liquid to remove extra sodium.

What to Avoid

Ms. Everett next highlighted some of the important foods for people with lupus to avoid. These foods include:

  • Foods high in saturated fat, trans fat, and cholesterol
  • Red meats and high fat meats like liver, organ meats, and dark meats.
  • Alcoholic beverages, salty foods, sugar sweetened beverages, candy, snacks, sweets, and alfalfa sprouts.
  • These foods can worsen side effects of steroids:
    • Simple carbohydrates and refined carbohydrates (often processed)
  • Overly processed foods:
    • Processed foods often have added salt and sugar, so try and eat fresh!
    • When foods are processed that means that modifications have been made to the product where fiber or vitamins were removed
    • Know that if a food or beverage has a food label it has been processed, so be aware of what is in it.

Lupus and Osteoporosis

Next, Ms. Everett spoke in greater detail on the role that osteoporosis plays for people with lupus and, again, some ways to practice a healthy diet.

It is important to understand that osteoporosis has no symptoms. There is no pain in the bones where individuals with osteoporosis would hypothetically feel sore, so it is important to speak with your doctor to have a regular bone mass density test performed. Again, there is a high risk of osteoporosis for people with lupus because of often decreased physical activity, vitamin D deficiency, medication side effects, and the additional risk of kidney disease. Listed below are nutritional tips to follow:

  • Be sure to include a high amount of calcium and vitamin D into your diet (see above for examples)
  • Limit caffeine, stop/avoid cigarettes, avoid alcohol, avoid salt:
    • Can have a depleting effect on calcium.
    • Smoking has been shown to have a direct effect on bone health, so speak to someone about a smoking cessation program.

Be aware of the effects of your medications

  • Corticosteroids can suppress inflammation.
    • e.g., Prednisone (Deltasone), Hydrocortisone, Methylpredisolone (Medrol), Dexamethasone (Decadron, Hexadrol)
    • When on these types of medications it is important to increase your intake of calcium and vitamin D, avoid salt, limit sugary foods and beverages, choose carbohydrates wisely, and - most importantly - use portion awareness.
    • Make sure to fill up with lower calorie foods; add fruits, vegetables, whole grains, and lean protein to your diet.
  • Methotrexate can cause sun-sensitivity & liver damage.
    • e.g., Folex, Mexate, Rheumatre
    • It is important to avoid alcohol and NSAIDs (medicines like aspirin, motrin) when on these types of medications. Adding folic acid supplements into your diet may also be helpful.
  • Anti-inflammatory medications
    • Aspirin and NSAIDs (Motrin, Celebrex, etc)
    • Be aware that certain foods can interact with prescribed blood thinners (such as certain vitamins and fish oils).
    • Medications can cause stomach irritation and bleeding ulcers, so be sure to take with food.

About Dietary Supplements

  • These are not regulated like drugs – do not have FDA approval
  • Can interact with prescribed medications, so definitely speak with your doctor before choosing to take any supplements or vitamins.
  • “Natural” does not mean “safe” or “effective”
Flaxseed

Some studies indicate that flax may protect against lupus nephritis (kidney disease associated with lupus). These studies are small and poorly controlled, therefore more research needs to be done to determine whether taking flaxseed supplements is helpful.

Vitamin D and Calcium

Is a bone building nutrient that helps to prevent or slow down osteoporosis. Aim to get 1000 - 1500 mg calcium and 400-800 IU vitamin D per day. Often hidden in foods like wild salmon (with bones), enriched/fortified soy milk, mushrooms (shitake), broccoli, kale, sardines (with bones), fortified milk, and fortified breakfast cereals.

DHEA: Dehydroephiandrosterone

Some studies indicate that DHEA may have a role in reducing flares and disease activity; also a role in decreasing the need for steroids. These studies, however, are small and poorly controlled, therefore further studies are needed to determine the safety and effectiveness of DHEA.

A note about supplements

It is important to not just rely on supplements to help improve your symptoms, as both diet and supplements together are important. Supplements are unregulated, so the quality and content may vary widely. You may need to take up to several doses per day of supplements to get the same effect that is in the food. Always try and consume the food before looking into supplements. Again, speak with your doctor.

When choosing supplements and vitamins, be sure to read the product labels carefully to make sure the ingredient lists make sense to you. Often some may have blood thinning effects. More studies need to be done to confirm the safety and effectiveness of supplements, so again, always consult with your doctor.

Supplements to be avoided:

  • Echinacea
    • Can contribute to flares if taken daily
    • Can stimulate the immune system
  • Alfalfa sprouts
    • L-canavanine (amino acid)
    • Possible increased SLE activity
    • Inconclusive, but use caution

Summary

Ms. Everett closed her presentation by going over some key take home points:

  • Make sure your diet is rich in a variety of nutrients:
    • Nuts, fish, dairy, olive oil, fruits, vegetables, whole grain, and spices are important.
  • Focus on foods high in antioxidants.
  • Changing your diet can be overwhelming for everyone, so take it one step at a time:
    • It is hard to change a diet when you are having a hard time, i.e., with depression, gut trouble, heart trouble, fatigue, fevers, and pain and difficulty using cooking utensils, but understand that this all takes time; do it one step at a time.
  • Incorporate batch cooking into your meal plans.
    • Cooking a big meal one night and freezing the rest for the week can help to save much needed time and energy.
  • Buy pre-cut or frozen fruits and vegetables.
  • Have easy and healthy cookbooks handy
  • Olive oil and canola oil should be your main sources of cooking fats.
  • Add lots of spices and limit added salt.
  • Choose foods that fight inflammation.
  • Aim for at least five servings of fruits and vegetables per day.
  • Obtain a good source of omega 3 fatty acids from fish, flaxseeds, and walnuts.
  • Maintain a diet high in fiber and low in sodium and cholesterol.
  • Keep your bones strong – be sure to get enough calcium!

Additional Resources

Learn more about the HSS SLE Workshop, a free support and education group held monthly for people with lupus and their families and friends.

See separate summary for Part 2: Enhancing Your Health with Nutrition: Focus on Specific Lupus-related Conditions: Cardiovascular Disease, Renal (Kidney) Disease, and other Lupus Risk Factors.

Summary Written by Christie Carlstrom, SLE Workshop Coordinator and Social Work Intern at HSS.

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