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Lupus Anti-Inflammatory Diet: Lifestyle changes advice [JUL 2023 UPDATE]

Lupus Lifestyle Changes (Diet and Exercise) are Important: Read here to learn about important dietary changes

Updated July 2023: Exercise improves gut bacteria (microbiome)

Though this post is about diet, a study showed that regular exercise and maintaining a “healthy” BMI were associated with a healthier microbiome (gut bacteria). See below.

Update in February 2023:

     -Increasing the amount of selenium and zinc may be beneficial for lupus (see full discussion below above the image of tomatoes). Foods include:

  • cold water fishes (salmon, mackerel, sardines, tuna, anchovies)
  • whole grains (quinoa, wild rice, brown rice, barley, etc)
  • seeds and nuts (especially walnuts, which are high in both omega-3 and omega-6 fatty acids)
  • lentils and other legumes

 

There is more and more evidence that healthy lupus lifestyle changes do make a difference. Read below for practical information regarding diet. 

 

Anti-Inflammatory Diet for Autoimmune diseases

This is the latest handout I give to my own patients. It has information from some of the latest medical research regarding foods to eat and avoid in order to hopefully decrease inflammation in the body. It talks about anti-inflammatory foods to eat, which to avoid, intermittent fasting, prebiotics (such as resistant starches), and probiotics. As per the Lupus Secrets, do this along with taking your medications, exercising regularly, getting at least 8 hours of sleep each night, and protecting yourself from ultraviolet light.

If you find this helpful, please share it with others.

There is growing evidence that eating a diet high in foods that decrease inflammation while avoiding, or minimizing foods that increase inflammation, can help autoimmune diseases such as lupus and rheumatoid arthritis. One of the latest studies from the University of California, San Diego Medical Center showed that rheumatoid arthritis patients had significantly better disease control when sticking to this type of diet. Lupus studies show that diets rich in omega-3 fatty acids and low in omega-6 fatty acids can help disease activity in people with lupus and mice with lupus. Lupus mice also have better disease control when they eat a diet rich in “resistant starches.” Resistant starches are discussed in the probiotics section below.  Note that the Mediterranean diet has many of these anti-inflammatory recommendations. You can find information online or ask your doctor for a copy of our Mediterranean diet.

oatmeal and yogurt probiotic foods for lupus lifestyle changes diet

Berries and nuts are high in anti-oxidants; oatmeal is an excellent prebiotic

 

Eat omega-3 fatty acids. Limit omega-6 fatty acids

 

Increase intake of:
Omega-3 fatty acids (walnuts, flaxseed, chia seed, salmon, tuna, mackerel, sardines, avocado, sesame seeds, tahini seeds)
Green leaf vegetables (such as arugula, broccoli, cabbage, zucchini, Brussel sprouts)
Anti-inflammatory vegetables (onion, carrots, pumpkin; eat garlic in moderation)
Enzymatic fruits (pineapples, mangos, papaya)
Anti-inflammatory spices (turmeric, black pepper, and ginger)

Decrease intake of:
Omega-6 fatty acids (reduce meat intake to turkey or chicken twice weekly; eat more fish as noted above; avoid or at least limit red meats, fried foods, and butter)

Increase the intake of foods rich in selenium

Lupus inflammation and damage on body organs involves a chemical process called oxidation. Beneficial enzymes that prevent oxidative damage are called anti-oxidative enzymes. Selenium is an important part of anti-oxidative enzymes. SLE patients tend to have lower blood levels of selenium. Selenium may be protective against lupus damage. Selenium occurs in meats, seafood, liver, grains, nuts, and seeds from selenium-rich soils. Therefore, it may be important for people from families with an autoimmune disease to ensure they get enough selenium in their diets.

The healthiest list of foods from these lists compatible with an anti-inflammatory diet include:

  • cold water fishes (salmon, mackerel, sardines, tuna, anchovies)
  • whole grains (quinoa, wild rice, brown rice, barley, etc)
  • seeds and nuts (especially walnuts, which are high in both omega-3 and omega-6 fatty acids)
  • lentils and other legumes

Tomatoes for an anti-inflammatory diet lupus diet

 

Nightshade foods and lupus? Avoid gluten?

Nighshade:

Do nightshade foods and lupus mix. Some experts recommend the following changes, while others do not due to insufficient data). Nightshade foods are probably fine to eat when you have lupus. At our 2020 American College of Rheumatology meeting, an anti-inflammatory diet research study was presented that did include nightshades. For example, tomatoes are rich in lycopenes, a strong anti-oxidant (so it seems they should be healthy rather than harmful).

Like with any food, if you predictably flare by eating nightshade foods, you should avoid them.

OCT 2022 addition: The Osher Clinic’s famous integrative medicine doctors include nightshade foods (like tomatoes) in its anti-inflammatory diet for lupus.

Gluten: 

Decrease the intake of gluten products (instead of wheat bread and pasta, switch to rye bread, corn tortillas, quinoa/beet/bean/ or chickpea pasta). However, most experts recommend avoiding gluten only if you truly have celiac sprue (gluten hypersensitivity).
*** NOTE: These recommendations are not for people who have celiac sprue, gluten-sensitive enteropathy, or gluten sensitivity. Though these are lower in gluten than wheat bread and pasta, some (such as rye) can contain gluten.

alarm clock representing intermittent fasting for a lupus diet

 

Intermittent Fasting

Fasting has been shown to decrease inflammation in the body in numerous studies.  Some lupus mice studies also show that fasting decreases lupus disease activity. Numerous animal models show that animals with a highly restricted diet live longer.

One easy way to fast is to do something called intermittent fasting. This form of fasting also lowers insulin spikes (so it may decrease the risk of diabetes), causes weight loss, and may help extend life span. 
An easy way to do intermittent fasting is to only start eating in the late afternoon, then stop when you go to bed. You only want to eat 8 or fewer hours a day and completely fast for at least 16 hours (including your 8 hours of sleep). You are only allowed water, black tea, and black coffee while fasting. Go to YouTube to watch some helpful videos about intermittent fasting.

If you have diabetes, discuss with your doctor before doing intermittent fasting (especially if you are on insulin).
You should also exercise regularly to get the full benefits of intermittent fasting. 

Petri dish with bacteria of the microbiome

 

The microbiome in autoimmune diseases:

We have trillions of bacteria living on and inside of us; all together it is called our “microbiome.” The insides of our intestines and gastrointestinal tract contain the largest immune system organ of our body, and the constant interactions of the microbiome bacteria and our immune system can either cause beneficial effects when we have good (beneficial) bacteria in our microbiome, or abnormal effects that can actually cause increase autoimmune disease. Studies of the microbiome and autoimmune diseases such as RA and lupus are in its infancy. Many studies have been performed in animals with lupus and RA, and smaller studies have been done in humans. We have so much to learn, but we do realize that having good bacteria that decrease autoimmunity, and getting rid of bad bacteria that increase autoimmunity are very important. Here are some recommended practices that you can do that may help you.

1. Take great care of your oral health! Poor dental health can actually cause RA and make it worse, and now there is evidence that it can do the same with lupus (in fact, one study showed that treatment of periodontal disease in lupus patients improved their lupus disease activity significantly.  Make sure and do the following:
     – Floss every day (flossing picks are very handy to use)
     – Brush twice a day
     – If you have a dry mouth, talk to your doctor about improving the much-needed saliva in your mouth to increase good bacteria and decrease the bad.
     – DO NOT SMOKE! (this is why smokers lose their teeth at a much younger age than nonsmokers)
     – Chew on gum that contains xylitol (or use Xylimelts, or use mouthwash that contains xylitol eg TheraBreath Maximum Strength)
     – Get your teeth cleaned every 6 months (every 3-4 months if you have a dry mouth)

2. Improving the microbiome in the gut has less medical evidence behind it. It is probably important to do, but we lack good large studies on humans. However, increasing the number of resistant starches in your diet may be beneficial.
– Resistant starches include cold oatmeal (eg overnight oats), potato starch, green banana starch, potatoes that are cold after being cooked, and lentils
     – These starches aren’t digested well until they get into the large intestine, where they begin to ferment. Then beneficial bacteria use these starches for food and interact favorably with the immune system and also decrease the numbers of bacteria that cause immune system problems.

A study on lupus mice fed a high resistant starch diet showed that their gut microbiome improved with bacteria beneficial to the immune system. Their immune systems became less inflammatory, and their lupus improved. 
     – Including a serving of resistant starches in your diet daily is probably a good idea.

Don’t forget to exercise to help your gut bacteria (microbiome)

A 2023 study showed that those who maintained a “healthy” BMI plus performed more than 150 minutes of moderate aerobic exercise per day had healthier microbiomes. It also showed this to be true in those with a strong hand grip (a surrogate measure of muscle strength).

Above, I put healthy in parentheses due to the BMI not being an accurate measure of a healthy weight in everyone. Someone with little muscle mass (sarcopenia) can be medically obese (due to too much fat weight in proportion to lean body mass) can have a BMI considered “healthy.” Body builders can be in the obese category per BMI, yet be incredibly healthy if they have low amounts of fat weight. 

Lupus Lifestyle changes: Yogurt oatmeal and strawberries as probiotics for a lupus diet

 

Probiotics in autoimmune diseases:

Probiotic beneficial bacteria could potentially help the microbiome of the intestinal system. Probiotic supplementation to lupus mice show some benefits with improved disease activity. Bifidobacterium and Lactobacillus species (except L. reuteri) are among the probiotic bacteria that improved disease activity. Probiotics are live bacteria touted to have beneficial effects by living within our intestinal system and interacting with our immune system. While probiotic supplements have been shown to have some benefits for gastrointestinal problems (such as irritable bowel syndrome), no human studies have proven their benefit for autoimmune disorders yet. In animal research, some autoimmune disorders improve with some probiotic organisms while others actually worsen. Therefore, we do not recommend any probiotic supplements.  Probiotics may be beneficial for the microbiome as above.

However, many foods are rich in natural probiotics, and thus far, there are no studies suggesting that any of these foods make autoimmune disorders worse. Therefore, you may want to consider the possibility of consuming a daily portion of any of the following probiotic-rich foods:

Some doctors, especially gastroenterologists, may recommend that patients take probiotics for nonrheumatologic problems, such as stomach problems. In that case, I would recommend you look at the list of bacteria in the supplement. I would recommend avoiding products that contain Ruminococcus (blautia) gnavus and Lactobacillus reuteri. Both of these have worsened lupus in research studies. 

Getting probiotic bacteria from food sources is the safest option for now until we learn more about probiotic effects on lupus. 

Probiotic-rich foods:

Greek yogurt
Kefir
Kimchi (fermented, nonpasteurized)
Kombucha tea
Miso soup (warm, not boiled)
Tempeh
Sauerkraut, fermented, nonpasteurized (warm, not cooked too hot)
Fermented, nonpasteurized pickles
Dark chocolate (just a little, and NOT milk chocolate)
Cold green peas on salads
Olives
Natto (very healthy, but takes an acquired taste)
Beet kvass
Fermented beets
Cottage cheese containing live cultures (eg “Good Culture” and “Horizon organic”)
Soft, aged cheeses (especially gouda; but also parmesan, cheddar and swiss; the longer the aging, the higher the probiotic content)

Prebiotics:

Don’t forget to feed your healthy gut microbiome and the probiotic bacteria you eat by ingesting prebiotics (food for your probiotics).

Lupus mice fed a prebiotic called “resistant starches” developed less lupus disease activity, improved beneficial bacteria in their gut, and improved immune systems. This is exciting to know that we may be able to improve lupus by the foods we eat.

Examples of “resistant starches” include:

-cold oatmeal after it is cooked

-cold potatoes (after cooking them)

green plantains

beans

legumes

cooled brown rice after it is cooked

-barley.

Avoid alfalfa sprouts and mung bean sprouts

Macaque monkeys fed a diet high in foods containing the amino acid L-canavanine (like alfalfa sprouts and mung bean sprouts) developed lupus-like disease with autoantibodies (like anti-dsDNA), hemolytic anemia, and kidney inflammation. This was repeated in another study.

Lupus mice fed a diet high in alfalfa sprouts had worsening of their lupus.

 

Garlic or no garlic?

Yes, you can eat garlic when you have lupus!

Unfortunately, there are some well-respected lupus websites (like Johns Hopkins) that still recommend not eating garlic. However, this is not based on any research data or even anecdotal data at all. There are no studies showing negative effects on lupus or any other autoimmune disease.

However, garlic was included in an anti-inflammatory diet study at the University of California, San Diego, by Dr. Monica Guma and others. It showed beneficial effects on the related autoimmune disease, rheumatoid arthritis. (note, this study excluded nightshades. However, other experts recommend nightshade is discussed above.)

Lupus anti-inflammatory diet food pyramid Sarah Patterson MD and Sara Tedeshi MD

The lupus anti-inflammatory diet food pyramid from the Osher Center for Integrative Medicine, University of California San Francisco (reprinted with permission from Dr. Sarah Patterson)

 

Alcohol and Lupus

NOTE: Do NOT drink alcohol without your doctor’s permission. It should be avoided in some medical situations (like severe liver disease) and with some medications (although it has recently been shown to be safe in moderation with methotrexate). People predisposed to alcoholism (such as those with a family history of alcoholism or a history of any drug abuse) should avoid all alcohol.

Evidence shows an association between low to moderate alcohol consumption and beneficial effects on lupus (discussed below). The highly regarded Osher Clinic has even included red wine (in moderation) as a part of its recommended anti-inflammatory diet.

The section below is from the 2nd edition of “The Lupus Encyclopedia” (with some minor changes) which is under production at Johns Hopkins Press as of October 2022 with hopefully a late Spring 2023 release date: 

Alcohol has been shown to have anti-inflammatory effects and may protect against lupus. A recent 2020 Harvard (Boston, Massachusetts) research study of over 200,000 women measured immune system levels seen in lupus. Those who drank alcohol had lower stem cell factors, which is an abnormality that we see in SLE patients. Numerous studies show that women who drink moderate amounts of alcohol have a reduced risk of developing lupus. Whether it can also decrease lupus disease activity is suggested in studies. However, we still need a randomized double-blind controlled trial to prove this theory.

Moderate alcohol intake may decrease the risks of cardiovascular disease problems (heart attacks, strokes, blood clots) and increase HDL good cholesterol levels. However, heavy alcohol drinking (especially binge drinking) increases the risk of death from heart disease (sudden cardiac death). It may increase the risk of breast, esophagus, mouth, throat, colon, pancreas, liver, and lung cancers.

Heavy alcohol use also increases the risk of depression, can have bad social consequences, gout (arthritis due to high uric acid levels), pancreatitis (inflammation of the pancreas), low blood cell counts, nerve damage, brain damage, dementia, liver damage (cirrhosis), and heart muscle damage. Worse, any alcohol can impede reflexes and increase the risk of a motor vehicle accident while driving, putting others’ lives at risk.

Before drinking alcohol, first double-check with your doctor to ensure it is not forbidden with your medicines. Prednisone, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, antidepressants, opioids, and methotrexate can potentially have more side effects if taken with alcohol. However, low to moderate consumption of alcohol with methotrexate is probably OK.

If you drink alcohol, it is really important to drink a moderate amount or less. Women (and men older than 65) should not drink more than one serving of alcohol within twenty-four hours. In contrast, men younger than 65 should not drink more than two servings. One serving is approximately 12 ounces of beer, 8 ounces of malt liquor, 5 ounces of wine, 3 to 4 ounces of fortified wine (such as sherry and port), 2.5 ounces of 24% alcohol liqueur, or 1.5 ounces of 80-proof liquor.

There is evidence that red wine may have more health benefits than other alcohol forms. It has antioxidants. However, this has not been proven.
If you do not drink alcohol, we do not recommend that you begin. You should reduce your intake if you drink more than the recommended amounts above. If you are a woman, consider taking a daily folic acid supplement. Some suggest that alcohol may increase the risk of breast cancer in some women. Taking daily folic acid may reduce this risk.

If you are at increased risk of harm from alcohol (such as a history of drug or alcohol abuse, liver disease, or a family history of breast cancer), then you should consider abstaining.

Think of alcohol as a drug. In small to moderate amounts, it may have beneficial health effects. In large amounts, it is dangerous, causing harm to the person (dementia, heart failure, nerve damage, liver failure, etc) but also to society (death from motor vehicle accidents, damage to relationships, etc.)


Dietitians/Nutritionists:

Consider seeing a dietician who specializes in lupus and anti-inflammatory diets. If you have any to recommend, please let us know in the COMMENTS. Examples:

The Lupus Dietician (Tanya Frierich)

  •  Does virtual visits as well as in person (North Carolina)
  • Email: tanya@tanyabnutrition.com, Facebook: facebook.com/thelupusdietician, Instagram: instagram.com/thelupusdietician


References:

Other studies are linked in the above post in addition to the studies below:
Bustamante MF, et al. Contemp Clin Trials Commun 2020
Guma M, et al. Trial of diet to improve RA and impact on the microbiome. Presented at ACR Convergence 11/9/2020.
Zegarra-Ruiz DF, El Beidaq A, Iñiguez AJ, et al. A Diet-Sensitive Commensal Lactobacillus Strain Mediates TLR7-Dependent Systemic Autoimmunity. Cell Host Microbe. 2019;25(1):113-127.e6. doi:10.1016/j.chom.2018.11.009

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written by Donald Thomas, MD
author of “The Lupus Encyclopedia
Arthritis and Pain Associates of PG County
301-345-5600
www.arthritispainpg.comRuminococcus (blautia) gnavus

10 Comments

  1. Hey Doc, just smallish point. If you’re avoiding gluten, rye bread is off the table. Gluten-containing grains are wheat, rye, barley, spelt and oats. (Oats don’t contain gluten as such, but a similar substance that reacts the same way in coeliacs and people with gluten intolerance.)

  2. Iris: Thanks so much for the commentary. You are absolutely correct. This comes directly from the UCSD anti-inflammatory diet study. They recommended lower amounts of gluten, and not complete avoidance.
    However, it is important to point this out so as not to injure those who are truly sensitive.
    So I added the phrase, people with “celiac sprue, gluten-sensitive enteropathy, or gluten sensitivity” should not eat these foods.
    That was important, so thank you!

    • Thank you Dr Thomas,
      Very informative!
      I have a friend who is going through
      initial stages of an autoimmune diagnosis. I ran acoss your information while searching to glean some autoimmune diet knowledge which we could implement now, along with food journaling.

      Much appreciated!

  3. […] Bottom Line on Diabetes vs having Lupus and Stroke & Heart Attacks . Exercise regularly healthy (strongly consider eating an antiinflammatory diet)Reduce stressGet plenty of sleep practice daily mindfulness don’t […]

  4. […] Lupus Nephritis Diagnosis: Now in a nutshell in this video. Preventing and treating lupus nephritis takes a lot more than taking drugs. Eating an anti-inflammatory diet, exercising regularly, practicing mindfulness, learning how to lower stress, seeing your doctors […]

  5. If an AIP diet excludes foods containing Lectins because it is said that they contribute to Leaky Gut how can they be beneficial to the immune system as as resistant starches? Does soaking with apple cider vinegar or consuming sprouted or fermented high Lectin foods help with inflammatory reactions by break down phytic acids?

    • MH: Great question, and here are my thoughts…

      1. The theory behind lectins and autoimmune disease are simply theoretical and not proven (i.e. …. show me a lupus study of any sort, or even autoimmune disease of any sort, and show me they cause worse disease.) … I could not find any (but I do realize that some sites, even Harvard, suggest this, but without proof). The studies are old… see below.

      However, the resistant starch study I mentioned was actually done on mice with lupus. In mice studies, you can 100% control their diet, so you know exactly what they are eating (unlike human studies), and you can see what that gut microbiome and immune system actually do… here is the study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6377154/

      Also, see figure 1 here: https://www.frontiersin.org/articles/10.3389/fimmu.2021.686501/full

      It is far from perfect, as we would like to see a nice human lupus study looking at the same thing. Nonetheless, it is better research and science compared to a “theoretical” opinion paper. Just like garlic… Johns Hopkins should remove the “stay away from garlic” off their website, for similar reasons (there is no evidence whatsoever that garlic is bad for lupus nor any other autoimmune disease)

      The science of diet, the microbiome, and autoimmune disease is in its infancy. Yet, we are finally starting to see good research show up…. some other great ones are from New York, Dr. Gregg Silverman’s lab: https://ard.bmj.com/content/78/7/947

      REF:
      Vasconcelos IM, Oliveira JT. Antinutritional properties of plant lectins. Toxicon. 2004 Sep 15;44(4):385-403.
      Freed, DLJ. Do dietary lectins cause disease? The evidence is suggestive—and raises interesting possibilities for treatment. BMJ. 1999 Apr 17; 318(7190): 1023–1024.
      Zegarra-Ruiz DF, El Beidaq A, Iñiguez AJ, Lubrano Di Ricco M, Manfredo Vieira S, Ruff WE, Mubiru D, Fine RL, Sterpka J, Greiling TM, Dehner C, Kriegel MA. A Diet-Sensitive Commensal Lactobacillus Strain Mediates TLR7-Dependent Systemic Autoimmunity. Cell Host Microbe. 2019 Jan 9;25(1):113-127.e6. doi: 10.1016/j.chom.2018.11.009. Epub 2018 Dec 20. PMID: 30581114; PMCID: PMC6377154.

      Donald Thomas, MD

      • There are lots of anecdotal accounts from people with lupus, myself included, that garlic increases pain/disease/flares. If I consume too much garlic, by the next day my hands will ache terribly. I have tested with adding and removing garlic and other foods and gave narrowed it down to garlic being the cause.

        My rheumatologist says some of her patients do better with more garlic and some do worse, and told me to continue to eat garlic but just in small amounts

        • Helen: thanks for sharing your experience with others. We do see this type of problem with (triggers) with lupus and rheumatoid arthritis as well where someone easily identifies a reliable trigger (eg tomatoes, etc) while very few others have this problem. It most like has to do with that particular person’s immune system and how it responds to various substances such as that.

          I agree with your rheumatologist, I recommend that patients always avoid any trigger that they personally identify, even if it is not proven to be a trigger in research studies.

          Donald Thomas, MD


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