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Nutrition and Lupus Part 2: Focus on Specific Lupus-related Conditions: Cardiovascular Disease, Renal (Kidney) Disease, and other Lupus Risk Factors

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

Introduction

This is the second presentation this year from Clinical Nutritionist Sotiria Everett and Part 2 of our Nutrition and Lupus series. In this presentation, Ms. Everett focuses more specifically on the heart and renal (kidney) disease as these relate to nutritional considerations for people with lupus. (See Part 1 for a more general overview of nutrition and its importance for people with lupus.)

Heart Disease

Ms. Everett began her presentation by discussing some important general facts about heart disease. Heart disease is still the leading cause of death in the United States. Heart disease is a slow and silent process. Often patients will not feel any symptoms, so it is important to be aware of the risk factors that are at play. Factors such as high blood pressure, high cholesterol, tobacco use, diabetes, physical inactivity, and poor nutrition can put people with lupus at an even greater risk for heart disease, or for worsening symptoms. It is important to understand that there are a lot of “little” things you can do to help reduce your risk.

Lupus and Heart Disease

Ms. Everett next highlighted some of the important issues that relate to lupus and heart disease:

  • Corticosteroids (prednisone) can lead to hardening of the arteries, known as atherosclerosis.
  • Atherosclerosis is a common cause of heart disease in people with lupus.
  • Kidney disease in association with lupus can affect the heart.
  • Women with lupus have a higher risk of heart disease than the general population.
  • Women with lupus are more likely to present risk factors such as high blood pressure (hypertension), high triglycerides, high cholesterol, and high homocysteine levels.

So what can you do?

All of these risk factors are important to be aware of. There is still much you can do to limit or lessen your risk from future disease. Ms. Everett highlighted that although we are unable to change risk factors like our genetics, gender, and age, there is still much we can do to lessen our risk. Some techniques that Ms. Everett discussed included controlling risk factors of heart disease by increasing physical activity, going to physical therapy, practicing healthy eating habits, seeking out a nutritionist, joining a smoking cessation program if you are a smoker, controlling your weight, and so on. It is very important that you keep in close contact with your doctor in order to control and monitor lupus and the medicines you take.

Goals to a Healthy Heart

  • Keep your low-density (LDL) “bad” cholesterol below 100mg/dL
  • Maintain your total cholesterol below 200 mg/dL
  • Keep your high-density (HDL) “good” cholesterol above 40 mg/dL
  • Triglycerides below 150 mg/dL
  • Fasting glucose “blood sugar” below 100 mg/dL
    • Prednisone can raise your blood sugar, so make sure you maintain a healthy blood sugar level
  • Control your blood pressure by keeping it below 120/80 mm Hg

Ms. Everett describes these all as therapeutic lifestyle changes, and not a diet or something you will do once in a while.

  • Limit saturated fat to less than 7% of calories per day (13 grams for a 2000 calorie diet). Saturated fats come from both animal and plant sources. Examples of animal sources are butter, lard, and shortening, as well as fat in meats, poultry, and whole milk dairy products. Plant source examples include palm oil, palm kernel oil, and coconut oil. Choosing monounsaturated fats and polyunsaturated fats can benefit heart health when replacing saturated and trans fats. Monounsaturated fats, including olive oil, canola oil, peanut oil, sunflower oil, and sesame oil, as well as avocados, peanut butter, and many nuts and seeds provide no more than 25-35% of calories and often contain vitamin E. Polyunsaturated fats contain essential fats including omega-3s and omega-6s. Sources of polyunsaturated fats include:
    • soybean oil
    • corn oil
    • safflower oil
    • fatty fish such as salmon, mackerel, herring, and trout
    • walnuts and sunflower seeds.
  • Limit trans fat to less than 1% of calories.
    • Avoid foods that contain partially hydrogenated oils.
  • • Limit cholesterol to less than 200 mg/day.
    • Choose fruits, vegetables, poultry, legumes, grains, and low-fat dairy, and be sure to watch your portion sizes.
  • • Limit sodium to 2000 mg/day.
    • Sodium is found naturally in foods in small amounts. Note that one teaspoon of salt contains approximately 2300 mg. Salt is often added to processed foods such as frozen meals; canned soups and sauces; pudding mixes; breads, cereals and muffins; soy sauce; cheeses; canned vegetables and canned fish; smoked meats, and cold cuts. When buying food, compare sodium content on food labels. Do your best to eat natural and fresh foods. Use spices and herbs to enhance flavor, rather than salt. Excess sodium intake can cause high blood pressure, kidney disease, heart attack, stroke, swelling/edema, and osteoporosis.
Sodium Recommendations:
  • American Heart Association
    • General Population: less than 2,300 mg of sodium per day.
    • African Americans, those in their middle-age, older adults, and people with diabetes, kidney disease, and high blood pressure: less than 1,500 mg per day.
  • Institute of Medicine of the National Academy of Sciences
    • Adults 19-50: 1,500 mg
    • Adults 50-70: 1,300 mg
    • Adults 71+: 1,200 mg
Reading food labels is very important when watching your sodium intake, so look for:
  • Sodium free or no sodium - less than 5 milligrams of sodium and no sodium chloride in ingredients
  • Very low sodium - 35 milligrams or less of sodium
  • Low sodium -140 milligrams or less of sodium
  • Reduced or less sodium - At least 25 percent less sodium than the regular product
Other recommendations:
  • Consume alcohol in moderation
  • Avoid exposure to tobacco products
  • Maintain normal blood sugar levels
  • Maintain a healthy weight

To maintain a healthy weight, it is important to know approximately how many calories you need to eat each day. Ms. Everett discussed that men require about 2200-2400 per day, whereas women require about 1800-2000 calories per day. Try and exercise for at least 30 minutes daily to help maintain your weight. It is important to reduce abdominal obesity where waist circumference for men should be below 40 inches and, for women, below 35 inches. It is also important to maintain your body mass index (BMI) below 25.

Heart Healthy Foods and Nutrients

Next, Ms. Everett discussed in greater detail some of the important foods and nutrients that are important to lessen the risk of heart disease: Omega-3 fatty acids, soy protein, and fiber.

  • Omega 3 Fatty Acids

    A number of studies have shown that omega-3 fatty acids, particularly EPA and DHA, can contribute to heart health. Omega-3’s consist of alpha linolenic acid (ALA), docosahexaenoic acid (DPA), and eicosapentaenoic acid (EPA). Food sources of omega-3’s include the following:

    • Alpha linolenic acid (ALA)
      • vegetable oils, nuts, seeds, and soy foods
    • Docosahexaenoic acid (DPA) and eicosapentaenoic acid (EPA)
      • Fatty fish such as mackerel, salmon, herring, trout, sardines, or tuna

    There are many ways to boost your omega-3 intake, including:

    • Cook or marinade food with canola and soybean oil
    • Add ground flaxseeds to cereals, soups, and baked foods
    • Add walnuts to salads or snack mixes
    • Choose eggs high in omega-3
    • Eat two four-ounce servings of fatty fish each week

    Fish oil supplements:

    If you have heart disease, the American Heart Association recommends one gram of omega-3 fatty acids from DHA and EPS per day. Talk to your doctor before taking fish oil supplements to determine if they are right for you.

  • Soy Protein

    Soy protein is a low-fat protein alternative for meat and cheese. Some studies indicate that soy protein may also help reduce cholesterol. Further research is needed.

    Tips:

    • Add tofu to vegetable stir-fry
    • Have a soy patty instead of hamburger
    • Snack on edamame or soy nuts
    • Use soymilk in cereal and oatmeal
  • Fiber

    Fiber has been shown to help with weight control and blood sugar levels. Aim to eat at least 25 grams of soluble and insoluble fiber daily.

    • Soluble fiber
      • Helpful in lowering LDL cholesterol
      • Eat at least 10 grams daily
      • Sources: oatmeal, barley, beans, fruits, vegetables

    Ways to boost your fiber intake:

    • During breakfast, eat whole fruit instead of juice and choose high fiber cereal and oats
    • During lunch, add one cup of beans to salads and soup and have sandwiches on 100% whole wheat bread
    • During dinner, serve whole grains such as brown rice, quinoa, bulgur, and corn

    Here is an example of the difference between a low fiber and a high fiber breakfast:

    • Low fiber breakfast:
      • one cup sweetened cereal, croissant, and eight oz. coffee
        • 2.3 grams of fiber
        • 27 grams of fat & 105 mg cholesterol
    • High fiber breakfast
      • one cup old-fashioned oats, one slice whole-grain toast and eight oz. orange juice
        • 12.5 grams of fiber
        • five grams of fat

Smart Choices for a Heart Healthy Diet

  • Nuts
    • Rich in monounsaturated fats, vitamin E, magnesium
    • May lower cholesterol and triglycerides
    • Five ounces/week recommended
  • Fruits and vegetables
    • Provide fiber, antioxidants, folate, potassium, and vitamin C
  • Dark chocolate (70% cocoa)
    • Rich in cocoa phenols & flavonoids
    • Watch your portions
  • Green Tea
    • Rich in flavonoids. More research is needed to understand its impact.

Diet Types

Mediterranean Diet vs. Western Diet
  • The Mediterranean Diet consists of: fruits, vegetables, whole grains, legumes, fish, and olive oil. This diet is high in fiber and antioxidants and low in red meat and high-fat dairy.
  • Western-type Diets consist of red meat, dairy, butter, fats, processed foods and sugar, and salt.
DASH Diet (Dietary Approach to Stop Hypertension)
  • High in calcium, potassium, and magnesium
  • Low in sodium, saturated fat, and cholesterol
  • High in fiber
  • DASH Foods
    • 4-5 servings of potassium rich fruits and vegetables
      • Potatoes, sweet potatoes, spinach, zucchini, tomatoes, kiwi, bananas, apricots, oranges
    • 2-3 servings calcium-rich foods
      • Fat-free and low-fat milk products
    • 4-5 servings/week of nuts, seeds and legumes
      • Provide fiber, magnesium, and protein

Focus on Lifestyle Changes

Ms. Everett next discusses some key techniques that can help one in making positive lifestyle changes.

  • Make one diet or exercise change at a time
  • Try a food diary
  • Enlist family and friends for support
  • Talk to your doctor, nurse, and nutritionist
  • It’s ok to have a treat (once in a while)

Recipe Substitutes

In order to help you to begin to maintain your own healthy diet at home, Ms. Everett next provided some useful recipe substitutes to try and incorporate into your diet:

  • Add fruits to marinated meats instead of high sodium sauces
  • Purchase low fat or fat free dairy products
  • Use soy products as alternative to dairy
  • Use plain yogurt for sour cream recipe
  • Substitute whole eggs with egg whites or egg substitutes
  • Use oil in place of butter or margarine
  • Use heart healthy oils such as olive, canola, flax oil, walnut oil, and peanut oil
  • Use herbs and spices to flavor foods instead of salt
  • Use sugar substitute such as Splenda
  • Try whole grains (i.e., pastas, brown rice)
  • Cut the recommended fat or oil by half
  • Omit fat/oil and use a non-stick spray
  • Cut the recommended sodium by half or less

Healthy Cooking Methods

  • Steamed
    • Vegetables, chicken, fish
  • Boiled
  • Grilled
  • Roasted
  • Baked

Tips: instead of two slices of pepperoni pizza and an eight oz. Coca-Cola, which equals 14 grams of fat, 780 calories, 753 mg of sodium, and 75 mg of cholesterol, choose a roasted turkey sandwich on wheat bread with two teaspoons of light mayo, lettuce & tomato, along with a low calorie iced tea and one apple, equaling three grams of fat, 580 calories, 440 mg of sodium, and 28 mg of cholesterol.

Kidney Disease and Lupus

Next, Ms. Everett reviewed some important facts about kidney disease and some essential dietary recommendations for people with lupus. Lupus nephritis is a form of kidney disease that affects people with lupus. Lupus nephritis is inflammation of the kidneys in which tiny filters in the kidneys are damaged, resulting in a loss of kidney function. Retention of fluids causes weight gain and swelling and puffiness in the legs, ankles, and/or fingers. Lupus nephritis may be treated with corticosteroids or immunosuppressive agents.

  • Dietary Recommendations

    The dietary recommendations are very similar to those suggested for heart disease. Ms. Everett highlighted that patients should follow a heart healthy diet by keeping salt intake low and, depending on your blood work, cutting back on protein foods and avoid high potassium foods. This is very important to check with your doctor.

    Protein Foods

    Your doctor may advise you to limit the amount of protein in your diet. Since you would need to eat a smaller amount of protein, choose heart-healthy protein foods like fish, chicken breast, lean red meats, egg whites, low fat soy products, and low fat dairy products as your main protein sources. Limit servings of milk, yogurt, cheese, dried beans and peas, nuts and seeds, peanut butter, and some soy products, which are high in both protein and phosphorus. Phosphorus is a mineral that builds up in the blood as kidney failure progresses.

    High Potassium Foods

    If your doctor tells you to limit high potassium foods, these foods include avocados, bananas, cantaloupe, dried fruits, honeydew, kiwi, mangos, artichoke, dried beans & peas, pumpkin, potatoes, French fries, Spinach (cooked), oranges & orange juice, papaya, prune juice, milk, yogurt, ice cream, chocolate, molasses, salt substitute, seeds and nuts, sweet potatoes, tomatoes, tomato sauce, vegetable juice, and winter squash.

    Try to eat lower potassium foods such as apples, berries, grapes, lemons, peaches, canned pears, pineapple, plums, watermelon, vegetables carrots, cabbage, cauliflower, cucumber, eggplant, green beans, lettuce, onion, summer squash, sweet peppers, dairy substitutes (nondairy creamers, rice milk [unenriched]), sorbet or popsicles, nondairy whipped topping, popcorn (unsalted), pretzels (unsalted) and red licorice. Remember to watch your portions of these foods. The bigger the portion, the more potassium that is consumed.

    Other Health Risk Factors for People with Lupus

    Some other risk factors that can affect people with lupus are diabetes and osteoporosis.

    • Diabetes

      To lessen your risk for diabetes, be sure to limit sugary foods and watch your portions of carbohydrates, i.e., fruits, starches, milk/yogurt, desserts, and breads/grains. It is important to keep your heart healthy and to stay active.

    • Osteoporosis

      To lessen your risk for osteoporosis, be sure to stay active, maintain a healthy weight, stop smoking if you currently are, and get enough calcium and vitamin D.

Key Points

Ms. Everett summarized her presentation by sharing some key points that people with lupus should follow in order to maintain and also lessen their risk for developing future disease.

  • Limit unhealthy fats and sodium
  • Eat foods high in fiber
  • Choose antioxidant-rich foods
  • Eat two servings of fatty fish per week
  • Maintain a healthy weight
  • Exercise regularly

Ms. Everett concluded by speaking briefly about the nutrition services at Hospital for Special Surgery. She highlighted that meeting with a nutritionist can be effective if you are interested in a one-on-one consultation about your diet. For more information on a nutrition consultation at HSS, please call 212-774-7638 or 212-606-1293.

The Division of Rheumatology at HSS has also launched a cardiovascular disease (CVD) prevention counseling program for HSS patients with systemic lupus erythematosus (SLE) and/or positive antiphospholipid antibodies (aPL). This free-of-charge program, which is partially supported by the New York Community Trust and partially by HSS, will provide a basic assessment and education of the CVD risk factors in patients who participate in counseling.

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

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

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