1. Nutrition and Lupus: Myths and Realities
Jennifer H Anolik, MD, PhD
Division of Allergy, Immunology & Rheumatology
University of Rochester Medical Center
Rochester, New York
2009
Information to be covered includes diet modifications for general cardiovascular health, how what you eat may impact your lupus in a positive or negative way, the role of vitamin supplementation in lupus and in particular the importance of vitamin D

2. Lupus at the University of Rochester
The Lupus Clinic
Autoimmunity Center of Excellence: Our Division currently provides the leadership for this University-wide NIH-funded multidisciplinary center, one of only 8 in the country. Ongoing Lupus projects in the division under this center (Sanz, Looney, Anolik) include:
Unraveling the mechanisms that underlie the breakdown of B-cell tolerance in SLE
Defining abnormalities in B cells in SLE
Delineating the role of cytokines like interferon and BAFF in SLE
Understanding the immunological consequence of B-cell depletion and other targeted therapies in the treatment of SLE
Clinical Trials Program: Investigation of new, targeted biological interventions in SLE. The AIR unit has an active program in clinical trials in systemic lupus erythematosus supported in part by a grant from the Lupus Clinical Trials Consortium.

3. Topics for today
Diet
Cardiovascular health: low sodium, low cholesterol, low saturated fat diet
Omega-3-fatty acids over omega-6
Dietary supplements
Vitamins
Osteoporosis is common: Vitamin D and calcium
?Value of other vitamins
Herbal supplements/other
Little data

4. Summary NO SPECIFIC DIET FOR THE TREATMENT OF SLE EXISTS
However, based on animal studies and limited human studies…
Possible adverse implications for SLE
Excess calories
Excess protein
High fat, especially saturated and omega-6-fatty acids
L-canavanine found in alfalfa
Possible beneficial dietary compounds
Vitamin E
Vitamin A
Selenium
Fish oils (omega-3-polyunsaturated fatty acids)
Primrose oil
Flaxseed
Plant herb (Tripterygium wilfordii)
DHEA
Calcium and vitamin D
Limitations to this research are that the findings are based on relatively few
studies, many of which were without control groups or extrapolated from animal models.
No large-scale studies have been done with LE patients to substantiate the benefit, if any,
of these individual dietary interventions, and if they were conducted, the remission and
exacerbation pattern of LE may interfere with elucidating their effectiveness.

5. Complementary/alternative medicine
Complementary and alternative medicine includes all those types of medicine that, when mentioned by a patient, elicit a blank look from their physicians, and cause the physician to leave the room in a hurry
Complementary and alternative medicine includes all those types of medicine that, when mentioned by a patient, elicit a blank look from their physicians, and cause the physician to leave the room in a hurry

6. NCCAM Definition
Complementary and alternative medicine, as defined by the National Center for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.
Also defined as ‘diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine’.

7. Multifactorial nature of autoimmune disease
Triggering factors
Susceptibility
Genes
Environmental
Factors
Exogenous or Endogenous Antigen
Antecedents
Genetics
Dietary
Environmental
Occupational
Learned
Traumatic
Disease-induced
Drug-induced
Immune
Response
(cytokine and effector functions)
Trauma
Microbes
Antigenes
Toxins
Radiation
Drugs
Outcome?

8. Needs a functional medicine approach
Exogenous or Endogenous Antigen
Triggering factors
Susceptibility
Genes
Environmental
Factors
Antecedents
Genetics
Dietary
Environmental
Occupational
Learned
Traumatic
Disease-induced
Drug-induced
Immune
Response
(cytokine and effector functions)
Modulating factors
Nutritional Balance
Tolerance
Protection from Infection
Allergy
Autoimmunity
Inflammatory
function
Energy Production
Oxidative Stress
GI function
Neuroendocrine
function
Structural
Mind-Body

9. Usage of CAM is common
4 out of 10 Americans used CAM for chronic conditions
629 million visits with $27 billion being spent each year
Estimated that 60-90% of patients with arthritis have used CAM
About 65% of SLE patients have been reported to have used CAM in some studies
Lupus patients who use CAM tend to be younger and better educated
Among the 707 patients, 352 (49.8%) were found to use alternative therapies and at similar rates across Canada, the United States, and the United Kingdom. Users were younger and better educated than nonusers, exhibited poorer levels of self-rated health status and satisfaction with medical care, and had minimal to no objective evidence of worse disease (ac- cording to the revised Systemic Lupus Activit y Measure instrument).
Moore et al. Arthritis and Rheumatism 2000

10. Usage of CAM in SLE Moore et al. Arthritis and Rheumatism 2000
Every second SLE patient seen in a tertiay care center would be expected to use at least 1 form of alternative medicine. The most frequently used therapies are massage and relaxation techniques
Moore et al. Arthritis and Rheumatism 2000

11. 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

12. First do no harm!
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

13. First 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
Herbals are made from the flowers, leaves, roots, berries, seeds, gel, bark & aerial parts of various plants.

14. Herbal remedies
Herbal remedies promoted for the treatment of arthritis include ginger, Chinese Thunder God Vine, willow bark extract, feverfew, cat's claw and stinging nettle.
Ginger and willow bark extract: Evidence for pain relief; But contain chemicals that are similar to conventional nonsteroidal anti-inflammatory compounds (NSAIDs); don’t use with warfarin
Cat's Claw - May increase the risk of bleeding if taken with blood-thinning drugs (e.g. Warfarin, Heparin)
Stinging Nettle - May increase the effects of tranquilisers and sedative drugs. May decrease the effect of certain cardiac and diabetic drugs
Thunder God Vine- Used for over 2000 years in Chinese medicine, 5 open trials- total of 248 patients with lupus with improved fever, rash, fatigue, lymphadenopathy, and laboratory abnormalities. Some serious side effects: GI upset, infertility
Evening Primrose Oil (EPO). EPO was reported to increase survival time in autoimmune
mice,95 and this may be due to its gamma-linolenic acid (19%) content from which PGE1 is
formed. Several studies support the role of PGE1 treatment alone in delaying the onset
and severity of lupus in autoimmune animals This beneficial effect of PGE1 might be
due its anti-inflammatory effects via membrane stabilization and lowering lymphocyte
activity.99
While there is some evidence that ginger and willow bark extract may relieve pain, these remedies contain chemicals that are similar to conventional nonsteroidal anti-inflammatory compounds (NSAIDs) like naproxen (Aleve) and ibuprofen (Advil). NSAIDs may cause inflammation of the stomach and intestines. Further, they can interfere with blood clotting and lead to fluid retention, causing problems for people with high blood pressure or heart failure.
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.
Bromelain (Pineapple enzyme) - May increase the effect of blood-thinning drugs (e.g. Warfarin, Heparin).
Cat's Claw - May increase the risk of bleeding if taken with blood-thinning drugs (e.g. Warfarin, Heparin).
Cayenne Pepper - Reports of possible interaction with MAO inhibitors and antihypertensive therapy (used to lower blood pressure). In large quantities, may cause damage to liver and kidneys.
Chamomile - Contains coumarin, but chamomile's effects on the body's anticoagulation system have not been studied. If used with anticoagulants such as warfarin, close monitoring by a doctor is advised.
Devil's Claw - May interfere with antacids, cardiac or diabetic medications. Use with caution is taking NSAIDs, which can irritate the stomach, as it can stimulate stomach acids.
DHEA - May cause liver damage if taking azathioprine or methotrexate. Can increase insulin resistance or sensitivity in diabetics.
Dong Quai - May interact with blood-thinning medications (e.g. Warfarin, Heparin). May increase sun sensitivity.
Echinacea - May be toxic to the liver if used for more than eight weeks. Should not be used with drugs that can cause liver problems, such as anabolic steroids, amiodarone, methotrexate and ketoconazole. Should not be given with immunosuppressants such as corticosteroids and cyclosporine because it can stimulate the immune system.
Evening primrose oil and borage (GLA) - Should not be used with anticonvulsants because they may lower the seizure threshold. Not recommended for patients diagnosed with schizophrenia. May increase the effects of anticoagulants and NSAIDs.
Feverfew - Effect on migraine headaches may be compromised by non-steroidal anti-inflammatory drugs, such as aspirin and ibuprofen. May increase blood-thinning effect of Warfarin or other anticoagulants, including NSAIDs. Not to be used if pregnant, as it may cause miscarriage.
Fish Oil (Omega-3 fatty acids) - May increase the blood-thinning effects of anticoagulants and NSAIDs.
Garlic - Should not be used with warfarin or other anticoagulents, because it affects clotting. May also interact with hypoglycemic medications, and anti-inflammatory drugs.
Ginger - Should not be used with warfarin because it affects clotting. Do not use if you have gallstones. Large quantities may interfere with cardiac, antidiabetic or anticoagulant (Warfarin, Heparin) therapy.
Gingko - Can inhibit clotting so should not be used with aspirin or other non-steroidal anti-inflammatory drugs or with anticoagulants such as warfarin or heparin. Also should not be used in conjunction with anticonvulsant drugs used by epileptics, such as carbamazepine, phenytoin and phenobarbital, or with tricyclic antidepressants.
Ginseng - Should not be used with warfarin, heparin, aspirin and other non-steroidal anti-inflammatory drugs because it can inhibit clotting. Also may cause headache, tremulousness and manic episodes in patients treated with phenelzine sulfate. Should not be used with estrogens or corticosteroids because it may add to those drugs' side effects. May also interfere with the heart drug digoxin or with digoxin monitoring. Should not be used by diabetics because it can affect blood glucose levels.
Goldenseal - Should be avoided by people with high blood pressure. May interfere with anticoagulant therapy (Heparin).
Karela - Should not be used by patients with diabetes because it can affect blood glucose levels.
Kava - Should not be used with the tranquilliser alprazolam because it may result in coma. Do not take with sleeping medications or tranquilisers.
Kelp - May interfere with thyroid replacement therapies.
Liquorice - Can offset the effect of the diuretic drug spironolactone. May also interfere with heart drug digoxin or with digoxin monitoring. Potassium loss due to other drugs, e.g., thiazide diuretics, can be increased.
Melatonin - Appears to boost the immune system, so should be avoided by people with autoimmune diseases including lupus.
St. John's Wort - Can produce skin reactions to light so fair-skinned users may wish to take care and anyone taking other drugs that cause light sensitivity, such as piroxicam or tetracycline, may want to avoid this herb. The active ingredient in St. John's Wort is uncertain, so it should not be used with two common types of psychiatric drugs called monoamine oxidase inhibitors and selective serotonin reuptake inhibitors. Tannic acid in the herb may inhibit absorption of iron. Can block the effects of drugs, including oral contraceptives, tricyclic antidepressants, cyclosporin, several heart drugs and warfarin.
Stinging Nettle - May increase the effects of tranquilisers and sedative drugs. May decrease the effect of certain cardiac and diabetic drugs.
Valerian - Should not be used with barbiturates, such as thiopental and pentobarbital -can cause excessive sedation. Do not use if taking tranquilisers or sleep medications, as it increases the effect.
White willow bark - Aspirin is made from the drug salaicin, which is contained in White Willow Bark .Do not take with aspirin or other NSAIDs, as it increases their effects. May increase the effects of anticoagulant drugs (e.g. Warfarin, Heparin).
Which herbs to use
Arthritis
Cat's claw, Aloe juice, Heartsease, Sweet violet, Cowslip, Thyme, Borage, Rosemary, Meadowsweet, Evening primrose, Willow, Yucca.
Muscle aches & pains
Black cohosh, Willow, Thyme, Meadowsweet, Cramp bark.
Headache
White willow, Passiflora, Valerian, Feverfew, Wild lettuce, Lavender, Black cohosh, Peppermint, Vervain.
Circulation problems
Hawthorn, Garlic, Ginkgo Biloba, Cayenne, Yarrow, Angelica, Mustard, Walnut.
Mouth ulcers
Myrrh, Liquorice.
Depression
Ginseng, Avena Sativa, Kava Kava, Cayenne, Cowslip, Rose, Thyme, Vervain.
Consider also - Flower essences.
Insomnia
Valerian, Passiflora, Chamomile, Lemon Balm, Kava kava, Hops, Catnip, Linden, Vervain, Cowslip. Lavender, Marjoram.
Migraine
Feverfew, Valerian, Vervain, Cayenne, Rosemary, Lavender.
Bruising
Yarrow, Arnica(ointment), Witch hazel, Calendula(ointment), Lavender(ointment).
Hypertension (High blood pressure)
Hawthorn berry, Garlic, Dandelion, Lime blossom.
Fatigue
Liquorice, Ginseng, Gotu Kola, Borage, Vervain.
Consider also - Flower essences. Plant Herb. Tripterygium wilfordii hook F (TWH), also known as Thunder God Vine, is a
plant that has been used in China for more than 2000 years to treat SLE and rheumatoid
arthritis In vitro tests support this traditional practice through evidence that the plant
has immunosuppressive qualities.110 Ramagolam reported that TWH inhibited
lymphoproliferation (mitogen-stimulated), production of cytokines by moncytes and
lymphocytes, and prostaglandin E2 production via the cyclooxygenase (COX-2) pathway.111
Despite the promising benefit of TWH, it is difficult to evaluate the use of herbal
therapies since their apparent successes and sometimes serious side-effects are often
not documented, particularly for renal patients.

15. Echinacea
Echinacea is popularly believed to be an immunostimulator, stimulating the body's immune system and warding off infections
A controlled double-blind study in the NEJM found that echinacea extracts had "no clinically significant effects" on rates or duration of infection after viral exposure
A controlled double-blind study from the University of Virginia School of Medicine and documented in the New England Journal of Medicine[3] stated that echinacea extracts had "no clinically significant effects" on rates of infection or duration or intensity of symptoms. The effects held when the herb was taken immediately following infectious viral exposure and when taken as a prophylaxis starting a week prior to exposure.

16. Echinacea
In one investigation by an independent consumer testing laboratory, five of eleven selected retail echinacea products failed quality testing
Reported adverse effects: allergy, TTP, leucopenia, abdominal pain, nausea, dysuria, arthralgia, myalgia
Should not be taken by persons with progressive systemic and auto-immune disorders; should not be used with immunosuppressants or hepatotoxic drugs
Four of the failing products contained measured levels of phenols believed to be related to potency below the levels stated on the labels. One failing product was contaminated with lead

17. DHEA Although not a nutrient or a dietary supplement, this
steroid hormone can be purchased over-the-counter
Naturally occurring adrenal steroid that is secreted mainly as DHEA sulfate
Works as a substrate for androgens and estrogens
Also has immunomodulatory effects
Large multi-center RCT with n=381
86/147 in the prasterone group (200 mg) vs 65/146 in placebo group had either stabilization or improvement in their disease
Lipid profile improved significantly and complement levels decreased
Acne and hirsutism were the most frequent side effects
Arthritis and Rheum46:2924, 2002

18. Probiotics
Probiotics are dietary supplements of live bacteria or yeasts thought to be healthy for the host organism. According to the currently adopted definition by FAO/WHO, probiotics are:
‘Live microorganisms which when administered in adequate amounts confer a health benefit on the host’

19. Probiotics
Intended to assist the body’s naturally occurring gut flora; claims to strengthen the immune system
Issues: Costly, lack of hard evidence
Recent data supported by the LRI showing benefit in lupus prone mice (FASEB Journal. 2008;22:lb477)
ABSTRACT
The lack of exposure to infectious agents in industrialized countries may compromise the development of effective immunoregulation. Microorganisms can evade the immune response via induction of tolerogenic APC and regulatory cells, and have been shown to prevent the development of autoimmune diseases. Probiotics, including Lactobacilli, from the normal flora play an important role in the immune system development. The goal of this study was to test whether probiotics prevent lupus development in (NZBxNZW)F1 mice and identify the mechanisms mediating protection. We have found that feeding Lactobacilli could delay lupus onset and severity. This protection was associated with an increase in the percentage of CD4+Foxp3+ cells and APC expressing B7-1 and B7-2 in the lymphoid organs, and production of high levels of IL-10 by T cells upon stimulation in vitro. Moreover, bone marrow-derived DC (BM-DC) stimulated with Lactobacilli also produced copious amounts of IL-10, and when transferred into (NZBxNZW)F1 mice delayed lupus onset and severity. In addition, significant increases in IL-10 levels were detected in most of the sera from mice injected with Lactobacilli-treated BM-DC. Altogether these data suggest that IL-10 may play a significant role in probiotic-mediated protection against lupus either directly, by suppressing pro-inflammatory responses, and/or by inducing regulatory cells. Supported by LRI.

20. Cardiovascular health:
Nutrition and lupus
Cardiovascular health:
diets low in saturated fat, omega-6-fatty acids, and cholesterol
Benefits of omega-3-fatty acids
Vitamins

21. Nutrition studies
Beneficial effects of protein and caloric restriction?
Severe caloric restriction delays the onset of glomerulonephritis in rats and mice (NZB/W)
Protein restriction especially of phenylalanine and tryptophan have a beneficial effect on lupus in rats
In general- not recommended: no evidence in humans; exception would be in the setting of kidney dysfunction

22. Nutrition studies
Diets rich in saturated fats and omega-6 fatty acids, and L-canavarine (alfalfa) have a deleterious effect on lupus in mice
Little to no human studies to date have confirmed these findings
One of the few human studies in which SLE patients reduced their omega-6 polyunsaturated fatty acid intake found that after one year, the number of patients with active SLE dropped from 11 to 3. Problems of interpretation:
Spontaneous improvement, placebo effects, and lack of a control group
Researchers studying the cholesterol-lowering effect of alfalfa
seeds observed signs of SLE-like symptoms in both laboratory animals and a few human
case studies Two human patients were reported to experience symptoms of malaise,
lethargy, depression, and arthralgias after ingesting 8-15 alfalfa tablets daily.45 In vitro
experiments suggest that L-canavanine, an amino acid in alfalfa products, acts on
suppressor-inducer T cells to regulate antibody synthesis and lymphocyte proliferation.46
Feeding L-canavanine to autoimmune mice resulted in increased antibody production and
higher renal histology scores.47

23. Foods high in omega-6- fatty acids
Sunflower, poppyseed, corn, wheatgerm, walnut, cottonseed, peanut, and sesame oil
Mayonnaise
Liquid margarine
Brazil nuts
Pine nuts
Pumpkin kernels

24. Fish oil and Omega-3-fatty acids in lupus
Majority of mice studies show that fish oils retard the development of lupus in mice
Human studies show modest results
In 1 RCT, 8/17 lupus patients given 6-8 grams of fish oil per day improved compared with 2/17 given placebo
In 2 other uncontrolled studies patients given large doses of fish oil did not show any improvements in DNA, immune complexes, or renal parameters
In a double blind study of 26 lupus patients who were followed for 2 years, there was no improvement in renal parameters or DNA antibodies. However, lipids did improve in the treated group.
In a small uncontrolled study of 9 patients with lupus, 30 grams of flax seed oil conferred some beneficial effects on renal parameters and atherogenesis
Recent small randomized study (3 gm) of 60 patients found small but significant improvements in disease activity
Wright SA, O'prey FM, McHenry MT, Leahey WJ, Devine AB, Duffy EM, Johnston DG, Finch MB, Bell AL, McVeigh GE.
Musgrave Park Hospital, United Kingdom.
OBJECTIVE: To determine the clinical effect of dietary supplementation with low dose omega-3-polyunsaturated fatty acids on disease activity and endothelial function in patients with systemic lupus erythematosus. METHODS: A 24 week randomised double-blind placebo-controlled parallel trial of the effect of 3g of omega-3-polyunsaturated fatty acids on 60 patients with SLE was performed. Serial measurements of disease activity using the revised Systemic Lupus Activity Measure (SLAM-R) and British Isles Lupus Assessment Group index of disease activity for SLE (BILAG), endothelial function using flow mediated dilation of the brachial artery (FMD), oxidative stress using platelet 8-isoprostanes and analysis of platelet membrane fatty acids were taken at baseline, 12 and 24 weeks. RESULTS: In the fish oil group there was a significant improvement at 24 weeks in SLAM-R (from 9.4+/-3.0 to 6.3+/-2.5, p<0.001); in BILAG (from 13.6+/-6.0 to 6.7+/-3.8, p<0.001); in FMD (from 3.0% ( ) to 8.9% ( ), p<0.001) and in platelet 8-isoprostanes (from 177pg/mg protein ( ) to 90 pg/mg protein ( ), p = 0.007). CONCLUSIONS: Low dose dietary supplementation with omega-3 fish oils in SLE not only has a therapeutic effect on disease activity but also improves endothelial function and reduces oxidative stress and may therefore confer cardiovascular benefits.
Wright et al., Ann Rheum Dis. 2007

25. Omega-3 fatty acids Fatty fish such as salmon, tuna, halibut
Canola Oil, flaxseed oil, hemp oil, soybean oil
Walnuts, flaxseeds, pumpkin seeds
Soy and tofu
Green leafy vegetables
Some eggs are enhanced with omega-3s

26. Flax seed
Two studies, one with mice and the other with human subjects, suggest that flaxseed may be beneficial in SLE
Eight humans with SLE were given 30 grams of flaxseed mixed in with their cereal or juice, and were reported to have improved renal function
Flaxseed contains natural antagonist of platelet activating factor, high in omega-3 fatty acid, alpha-linoleic acid
Possible allergic reactions
Flaxseed. Two studies, one with mice and the other with human subjects, suggest that
flaxseed may be beneficial.
A plant food

27. Atherosclerotic disease in SLE
Clinical CAD is very common in lupus cohorts: 6-10%
Women with SLE have a 5-6-fold increased risk of cardiovascular disease compared to the general population
Women aged years have a 50-fold increased risk!!
SLE patients are more likely to have certain classic risk factors: HTN, diabetes, obesity
‘SLE factors’
Bruce, Best Practice Res Clin Rheum 19:823, 2005

28. Overall survival in lupus has improved
CV dz
Gabriel S et al Arthritis Rheum 1999;42:46-50

29. Bimodal mortality pattern
Early mortality in lupus is due to active SLE or associated complications such as infection
Late death (>5 years after diagnosis) are frequently associated with atherosclerotic complications
Urowitz et al. Am J of Med 60:221, 1976

30. What can lupus patients do to decrease their risk of heart disease?

31. Ways to improve risk factors without medications
Reduced intake of saturated fat and cholesterol
Increased physical activity
Weight control
Stop smoking
Bruce, Best Practice Res Clin Rheum 19:823, 2005

32. Vitamins
There have not been adequate scientific studies proving that specific vitamins are helpful in treating lupus. However, it is important to have a good, balanced diet to maintain health

33. Vitamin E
Vitamin E has been advocated for lupus patients since the 1940s
Several positive studies have been reported
A closer look at the literature shows several negative studies as well
A recent meta-analysis of literature showed that high dose vitamin E over 400IU per day was associated with a higher mortality and higher incidence of heart attacks and strokes
MORE IS NOT NECESSARILY BETTER!
For a long time it was felt that anti-oxidant vitamins like E and C have beneficial effects for heart disease which they likely do but….
Several observational studies published in the 1990s suggested that higher vitamin E intake is associated with a significantly lower risk of cardiovascular disease (CVD) [1], [2], [3] and [4]. The Nurses Health Study and the Health Professionals Follow-up Study for example showed that higher vitamin E intake from supplements for more than 2 years significantly reduced the relative risk for coronary heart disease (CHD) [1] and [2]. Results from these studies were the catalyst for randomized controlled vitamin E intervention trials. The majority of these intervention trials, however, did not support the hypothesis derived from the observational studies [5] and [6]. Recently, unexpectedly, two meta-analyses of vitamin E intervention trials of CVD, cancer, and other diseases, reported an increased relative risk of all-cause mortality. Further, two individual vitamin E intervention trials reported increased risk of heart failure

34. Vitamin A
Vitamin A has been reported to have beneficial effects in SLE
3 patients with skin lesions were given vitamin A in high doses. In 1 week all lesions cleared up.
Other researchers have reported an improvement in immune function parameters with vitamin A supplementation
Caution advised to patients using vitamin A from animal sources as these are fat soluble and can accumulate and cause toxicity

35. Selenium
Selenium supplementation has been reported to be beneficial in lupus mice
No human studies
Caution advised as excess selenium can cause diarrhea, vomiting, hair loss, skin lesions, and nervous system dysfunction

36. Supplements to avoid Those containing: -protein (high meat diet)
-omega-6 polyunsaturated fatty acids
-zinc (also found in Brazil nuts and oysters, some supplemented cereals)

37. Vitamin D Vitamin D and osteoporosis Osteoporosis is common in SLE
recent observational study of 163 women with SLE
median age of 47
55% post-menopausal, 52% taking steroids, 85% h/o steroids
23% osteoporotic, 56% osteopenic
Vitamin D is important for bone health; vitamin D deficiency is extremely common
Recommend MVI with calcium and vitamin D in SLE to prevent and treat osteoporosis
Almehed et al. Rheum 46:1185, 2007 “Prevalence and risk factors of osteoporosis in female SLE patients”
163 women with SLE in Sweden. Observational cross-sectional study. Median age was 47, 55% were post-menopausal, 52% were taking steroids (median dose 5 mg) (85% had h/o steroid use). 23% were osteoporotic in at least one measured location (56% osteopenic). Bisphosphonates were used by 27% taking steroids and 35% with osteoporosis. High age and low weight were associated with low BMD. Also high SLICC, ESR, and combinations of DMARDs, but not steroids either current or cumulative on multiple regression. With multiple regression analysis disease duration was not significant. By simple regression even SLEDAI was not significant.
Almehed et al. Rheum 46:1185, 2007 “Prevalence and risk factors of osteoporosis in female SLE patients”

38. Vitamin D and lupus Vitamin D and autoimmunity
Vitamin D has potent anti-inflammatory properties, suppressing immune cells that take part in the autoimmune reaction
Vitamin D and Lupus
Supplementation of lupus mice with Vitamin D improves disease
Some studies have found a higher prevalence of vitamin D deficiency in SLE
Rheumatology (Oxford) Vitamin D deficiency in systemic lupus erythematosus: prevalence, predictors and clinical consequences.; Ruiz-Irastorza et al. ; ARD 2007 Vitamin D and autoimmunity: new aetiological and therapeutic considerations, Arnson et al.

39. Nutrition studies Recent study of 92 SLE patients
75% and 15% presented with vitamin D insufficiency and deficiency, respectively.
Female sex (P = 0.001), treatment with HCQ (P = 0.014) and treatment with calcium and vitamin D (P = 0.049) predicted higher levels of 25(OH)D.
Photosensitivity [odds ratio (OR) 3.5] and photoprotection (OR 5.7) predicted vitamin D insufficiency and deficiency, respectively.
Patients with vitamin D deficiency had a higher degree of fatigue as quantified by a 0-10 VAS (mean 5.32 vs 4.03, P = 0.08).
No relation was seen between vitamin D insufficiency or deficiency and disease duration, SLEDAI or SLICC-ACR indexes.
ACE study of vitamin D supplementation in SLE

40. Some points to remember
There are no magic cures for lupus. Do not be conned into spending money on a product that claims to be a 'cure-all'. If in doubt consult your doctor.
Do your homework- ?safety, ?efficacy
Natural Isn't Necessarily Safer
Herbal supplements are virtually unregulated
Little data regarding herbal treatments and lupus
please be careful when taking alternative medicines
avoid any herbal treatments that claim to ‘stimulate the immune system’

41. 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

42. Resources for more information
Arthritis foundation:
National Center for Complementary and alternative medicine:
Johns Hopkins review of alternative therapies for arthritis