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Pradeep Yarra

Citation: Pocovi-Gerardino G, Correa-Rodríguez M, Callejas-Rubio JL, et al. Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study. Rheumatology (Oxford). 2021;60(1):160-169. doi:10.1093/rheumatology/keaa210

Question 1:   Why is this study important?

Numerous studies have shown the benefits of adhering to a high-quality Mediterranean diet with a lower incidence of cardiovascular disease, metabolic syndrome, obesity, diabetes and recently on autoimmune diseases also.  Significant effect of this diet on the disease mechanisms and outcomes have been noted with rheumatoid arthritis and multiple sclerosis.  SLE remains one of the common autoimmune diseases and this patient's diarrhea very high risk of developing cardiovascular disease.  The study tries to analyze the influence of Mediterranean diet on SLE disease activity and cardiovascular disease risk markers.

Identify one key finding of this study and describe how it relates to nutritional sciences

This was a cross-sectional study which was performed on 280 patients with SLE under assessment of Mediterranean diet adherence was correlated.  Key findings from the study are:

1)     greater adherence to the Mediterranean diet was significantly associated with low disease activity which was calculated by the scoring systems, has improved inflammatory markers, and also had less active or inactive SLE disease

2)     significant correlation was also found between good Mediterranean diet adherence and low cardiovascular risk markers

3)     more interestingly the beneficial effect of midodrine rate was also seen in improvement of heart trouble metric data profiles like lower BMI and lower fat mass percentage

What are the clinical implications of this study?

This is the first study to assess the correlation of Mediterranean diet on the SLE disease activity.  This effect might be secondary to the changes in the immune system, inflammatory markers and other cardiovascular disease risk factors which eventually affect the course and prognosis of these patients.  Specifically, in patients who have additional comorbidities like obesity, metabolic syndrome along with the SLE, having a single dietary plan that includes Mediterranean diet would improve adherence and address multiple comorbidities at the same time

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Gioia, C., Lucchino, B., Tarsitano, M. G., Iannuccelli, C., & Di Franco, M. (2020). Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations? Nutrients, 12(5), 1456. MDPI AG. Retrieved from http://dx.doi.org/10.3390/nu12051456

This article directly relates to topics discussed in the material this week, as it covers Rheumatoid Arthritis and how certain diets can better or worsen the disease. Diet is known to have a large impact on RA and can lead to progression or risks of the disease. Items that decrease inflammation have been shown to prevent RA symptoms or development. The typical Western diet is said to be a strong risk factor considering a large portion of this diet is red meats, fats, or carbohydrates. This study further explained that diet is such a large contributing factor to most chronic diseases and for RA, excessive red meats and total protein are associated with inflammation that causes it. It is also interestingly noted that an individual’s gut microbiota plays such a critical role in RA. This journal basically reinforces the major concepts covered in this module related to RA with its symptoms, causes, effectors, and treatments.

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Scrivo, Rossana, Perricone, Carlo, Altobelli, Alessio, Castellani, Chiara, Tinti, Lorenzo, Conti, Fabrizio, and Valesini, Guido. "Dietary Habits Bursting into the Complex Pathogenesis of Autoimmune Diseases: The Emerging Role of Salt from Experimental and Clinical Studies." Nutrients 11.5 (2019): 1013. Web.
The study investigates how salt intake influences autoimmune disease. Recently, many people have autoimmune diseases in Western countries. It is an important observation to understand what relates between the patients' diet and the disease. The patients also absorb salt would contribute to proinflammatory. It will be an essential cook or choose the food in the patients' lives.

One key finding is sodium regulation of the immune system. Sodium would control the positive correlation cytokines. Suppose the scientists discover how much salt intake results in inflammatory in the patients' bodies. The nutritionists advise that the patients manage their salt intake so that the patients may decrease their incidence. Besides, the mechanism will advance the therapy for autoimmune disease.

The study collects the patients' questionnaire, and distinguish in different autoimmune disease. The researchers can analyze which cytokinesis results from sodium and target regulation of elements. It will help treatment for the patients.

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Everett, S T, Wolf, R, Contento, I, Haiduc, V, Richey, M, & Erkan, D. (2015). Short-term patient-centered nutrition counseling impacts weight and nutrient intake in patients with systemic lupus erythematosus. Lupus, 24(12), 1321-1326.

This study is important because patients with SLE disease are at higher risk of developing chronic diseases, such as cardiovascular diseases. Therefore, by considering patient-centered nutrition counseling and evaluating significant related parameters, such as anthropometric measures for six months, beneficial dietary habits can be achieved.

The main study finding was that after a 6-month period of patient-centered nutrition counseling, the SLE patients improved their food choices and intake, reduced their sodium and saturated fat intake, and increased their fruits and vegetable intake. Consequently, the risk of developing cardiovascular diseases can be decreased in those patients. However, due to a short intervention period, six months, there was not a significant improvement in lipid profile.

The study’s clinical implication is that patient-centered nutrition counseling would be aided in reducing the risk of developing cardiovascular disease in SLE patients. Therefore, RDs are advised to use a patient-centered nutrition counseling strategy with those patients.

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Grant W. B. (2000). The role of meat in the expression of rheumatoid arthritis. The British journal of nutrition, 84(5), 589–595. https://doi.org/10.1017/s0007114500001926

This study is important because it looks at the role meat plays on the risk of developing rheumatoid arthritis. Rheumatoid arthritis is an auto-immune disorder characterized by chronic inflammation in the joints. It might be difficult to see a link between diet and joints, but nutrition can play a big role on inflammatory response. For example, certain foods can be either pro-inflammatory or anti-inflammatory.

This study looked at per capita meat and offal fat relative to total energy alongside rheumatoid arthritis prevalence. There was a positive association that showed that rheumatoid arthritis prevalence increased with greater amounts of per capita meat and offal fat relative to total energy. The main key finding in this article is that fat from meat may lead to an increase in inflammation and free radical production. Inflammation and free radical production could lead to an increased risk of rheumatoid arthritis. Free radicals can promote oxidative stress and increase the inflammatory response which could promote an auto-immune response. However, dairy products also have a similar lipid profile to meats and they are not known to be associated with rheumatoid arthritis.

The clinical implications of this study would be to do more clinical and case-control studies to see if there is a significant relationship between rheumatoid arthritis risk and diets high in meat and offal fat.

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Fitzgerald KC, Tyry T, Salter A, Cofield SS, Cutter G, Fox R, Marrie RA. Diet quality is associated with disability and symptom severity in multiple sclerosis. Neurology. 2018 Jan 2;90(1):e1-e11. doi: 10.1212/WNL.0000000000004768. Epub 2017 Dec 6. PMID: 29212827.

Why is this study important?
MS is a disease without a curative treatment and many of the medications use are either ineffective or cause significant side effects. Any additional non-medication interventions for MS that could cut back on symptom burden should be discussed with patients.

Key Finding and Relation to Nutritional Sciences
While a healthy diet didn’t change the number of flares or progression of the disease, it did correlate with lower rates of depression as well as a lower PDDS score (patient determined disease step, higher scores are given for higher levels of debility). Patients with a “composite healthy lifestyle” (defined as BMI less than 25, non-smoking, engages in physical activity and consumes a better than average diet), rated their pain, fatigue and cognitive function better in addition to depression and debility.

Clinical Implications
This study broke patients up into quintiles based a score that included high fiber, whole grain and fruit/vegetable intake and low red/processed meats and added sugars. While dietary modifications haven’t been shown to reduce flares or slow progression, the metrics that this study looked at (disability score, cognitive function, fatigue, etc) are important to patients and can significantly improve their general quality of life.

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Gioia C, Lucchino B, Tarsitano MG, Iannuccelli C, Di Franco M. Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations?. Nutrients. 2020;12(5):1456. Published 2020 May 18. doi:10.3390/nu12051456

Although genetics is a factor of Rheumatoid Arthritis, the environmental trigger is the key to genetically predisposed people.  Healthy lifestyle can be helpful to prevent onset or development of RA.  According to this study, RA patients often ask their rheumatologist for self-management strategies such as dietary habit and what to eat/avoid, resulting in more attention among the practitioners to utilize dietary advice to improve efficiency of pharmacological treatment.  This study is important to see evidence-based observation of Mediterranean diet, vitamin D, alcohol, tea, omega-3, caloric restriction, gluten, fasting, vegan diet, probiotics and more.

This study report that, although there is no firm evidence in vitamin D to prevent RA, Mediterranean diets is a “protective dietary style” and effective suggestion of what to eat as well as weight control which affects on a remission stage and effectiveness of treatment.

This clinical implication is that, since RA is a long-term disease, the dietary manipulation and healthy lifestyle could be helpful to RA patients for less symptoms, slower progress, and less  pharmaceutical drug.

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Armon-Omer, A., Waldman, C., Simaan, N., Neuman, H., Tamir, S., & Shahien, R. (2019). New insights on the nutrition status and antioxidant capacity in multiple sclerosis patients. Nutrients, 11(2), 427.

This study combines nutrition, fatty acid panels, antioxidant capacity, and MS in a comparison between severity of MS and between MS patients and healthy controls. This is the first study of its kind to combine these panels and nutritional information into one study to understand differences along disease severity and between healthy controls and MS patients.

One key finding from this study from that MS patients had a significant decrease in saturated and unsaturated fatty acids, antioxidant capacities, decreased vitamin levels, and decreased ability to absorb nutrients. This decrease of levels and ability/capacity increased as MS disease severity increased.

This study could change how MS is treated clinically in the future. As this is the first of its kind, this study shows the important fact that, with such distinct nutritional panels and deficits, these all can be fixed with diet and exercise, which could greatly help in MS relapse and symptom severity. It'll be interesting to see how clinical treatments change as more information and guidelines come out to impact the dietary changes necessary for MS.

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Philippou E, Nikiphorou E. Are we really what we eat? Nutrition and its role in the onset of rheumatoid arthritis. Autoimmun Rev. 2018 Nov;17(11):1074-1077. doi: 10.1016/j.autrev.2018.05.009. Epub 2018 Sep 10. PMID: 30213695.

Rheumatoid arthritis is a long-term, autoimmune inflammatory condition affecting around 0.25% of the global population. There are several genetic and environmental factors such as diet, tobacco and smoking, that make someone more susceptible to rheumatoid arthritis. There is evidence that suggests that there are dietary factors that might act as environmental triggers in genetically susceptible individuals leading to the development of rheumatoid arthritis with an immune-inflammatory response. The inflammatory response includes the production of soluble immune mediators such as cytokines and chemokines by joint tissue cells such as synovial fibroblasts, synovial macrophages and chondrocytes which leads to joint damage. Diet consisting on excessive red meat, salt, or increased in food intake has been categorized as trigger foods while fatty fish, fruits, and vegetables have been shown to reduce inflammation. A “Western” diet which can be characterized as an increased consumption of saturated fats, trans fats, low ratio of omega 3 and 6 fatty acids, as well as an increased consumption of refined carbohydrates and sugar-sweetened beverages is directly related to the increase in inflammation and increase insulin resistance. Obesity represents a rising comorbidity in the presence of rheumatoid arthritis because of the increase in inflammation and insulin resistance. Diet can play an important role in the reduced risk of rheumatoid arthritis. Evidence suggests eating lean meats such as fish that have long chain omega-3 polyunsaturated fatty acids is associated with reducing the risk in females by 35%. Consuming foods that have strong anti-inflammatory properties is found to be important factors for reducing rheumatoid arthritis.  Promoting a healthy diet and lifestyle change can determine the future for many individuals that are more susceptible to certain diseases. I believe this study proves that an overall healthy diet and lifestyle can change the course for any disease onset.

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Dietary intervention and health in patients with systemic lupus erythematosus: A systematic review of the evidence

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Dietary intervention and health in patients with systemic lupus erythematosus: A systematic review of the evidence

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Citation:

Marília Cristina Santos de Medeiros, Jussara Cristina Alves Medeiros, Humberto Jefferson de Medeiros, José Carlos Gomes de Carvalho Leitão & Maria Irany Knackfuss(2019) Dietary intervention and health in patients with systemic lupus erythematosus: A systematic review of the evidence, Critical Reviews in Food Science and Nutrition, 59:16,2666-2673, DOI: 10.1080/10408398.2018.1463966

1) This study is important because it addresses the main side effect of lupus, inflammation and the effect of nutrient supplementations. Its addresses omega-3's, vitamin D, turmeric, and glycemic index.

2) There was no one finding that particularly stood out to me. However they did find that each supplement had some what of an impact. The concluded from the systematic review that omega-3 and vitamin D supplementation inflammation as well has having other positive effects. Turmeric had not effect on inflammation, but reduced pro- teinuria, hematuria and systolic blood pressure. A low glycaemic index diet caused weight loss and reduced fatigue. This relates to nutrition sciences because these are supplements and food groups we can recommend patients to consume. The idea that nutrition can play a part on lupus management is exciting.

3) As stated above with can support lupus treatment with an anti-inflammatory diet.

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Citation:

Dey, M., Cutolo, M., & Nikiphorou, E. (2020, October 15). Beverages in rheumatoid arthritis: What to prefer or to avoid. Retrieved February 08, 2021, from https://www.mdpi.com/2072-6643/12/10/3155/htm

1/2.)Why is this study important? What are the findings?

This study is important because it analyzes how different beverage consumptions can impact outcomes in RA patients. Different habitually consumed beverages were monitored. Key findings in this study show that high sugar diets increase the symptoms associated with CVD and RA. Amongst other findings, evidence was found that many drinks such as teas, fruit juices, and red wine, correlated with beneficial epigenetic, molecular, and clinical outcomes.

3.)What are the uses clinically?

In a clinical setting it would be very useful to give dietary counseling to those with RA. This has the ability to highlight the different impacts that the correct variety of different fluid intakes. A variety of beverages with diverse nutrient contents can be helpful on a case by case basis in order to control various symptoms that are indicated in RA.

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Anna K E Vadell, Linnea Bärebring, Erik Hulander, Inger Gjertsson, Helen M Lindqvist, Anna Winkvist, Anti-inflammatory Diet In Rheumatoid Arthritis (ADIRA)—a randomized, controlled crossover trial indicating effects on disease activity, The American Journal of Clinical Nutrition, Volume 111, Issue 6, June 2020, Pages 1203–1213, https://doi.org/10.1093/ajcn/nqaa019
This study is important because it addresses the effectiveness of a diet change in the treatment of rheumatoid arthritis. Ultimately, there wasn’t a single best diet in patients and it is important to note that the needs of the patient are quite specific. The results from the study did indicate that a diet rich in anti-inflammatory components and probiotics did correlate with a weaker disease presentation.

One key finding from this study was that the incorporation of probiotics was a key factor in decreasing disease presentation. An ineffective microbiome is often seen in patients with RA. Probiotics are a great way to generate a healthy gut flora which help to modulate inflammation.

The clinical implications of this study is that providers should strive to address the importance of adherence to an anti-inflammatory diet to help manage disease presentation. The diet should emphasize poly-unsaturated fatty acids and probiotics. This in combination with other lifestyle modifications will help the patient achieve a greater quality of life. I think it is important to consider the quantity and quality of anti-inflammatory foods that must be consumed in order to see effects at the clinical level. Is this quantity feasible for the patient to afford and incorporate on a daily basis?

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Citation:  Nezamoleslami S, Ghiasvand R, Feizi A, Salesi M, Pourmasoumi M. The relationship between dietary patterns and rheumatoid arthritis: a case-control study. Nutr Metab (Lond). 2020 Sep 17;17:75. doi: 10.1186/s12986-020-00502-7. PMID: 32963579; PMCID: PMC7499965.

Why this study is important

This study evaluates the relationship between major identified dietary patterns and RA, in a specific population.  Due to the lack of studies assessing dietary patterns and RA in Middle Eastern populations, this study specifically looks at dietary patterns of Iranian adults.  The authors noted that many past studies have focussed on the effect of individual foods or specific nutrients, but not on identifying major dietary patterns in this population.

The study is important for two reasons:  1) it studies a broader dietary food pattern in RA, important to better understanding dietary choices and influences that may contribute to RA risk factors, and 2) the study focusses on a specific geographic population, important to isolating how diet might impact disease in different parts geographic regions.

Key Study Finding That Relates To Nutritional Sciences

A 168-item questionnaire was used to collect dietary data which resulted in the identification of two primary dietary patterns that researchers labeled as Healthy and Western. The Healthy dietary pattern is more closely related to a Mediterranean diet (fish, egg, poultry, low-fat dairy, fruit) and the Western dietary pattern included processed food selections, red meat etc.

The study results showed that lower adherence to the Healthy dietary pattern was associated with an increased risk of RA, even after taking other potential factors into account such as age, BMI and sex.  The results also demonstrated a significant association between adherence to a Western diet as defined in this study, and RA.

Clinical Implications

While the study indicated that additional research continues to be necessary to conclude that the Western diet as defined, has a causal effect on RA, the clinical implications continue to support that a Mediterranean (Healthy) dietary pattern may be supportive in preventing RA presentation, perhaps by altering systemic inflammatory responses.  As noted earlier, it is also important that this research is conducted in different study populations to find or eliminate additional variables that my impact the dietary pattern conclusions and global treatment recommendations.

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Essouma, Mickael, and Noubiap, Jean Jacques N. "Therapeutic Potential of Folic Acid Supplementation for Cardiovascular Disease Prevention through Homocysteine Lowering and Blockade in Rheumatoid Arthritis Patients." Biomarker Research 3.1 (2015): 24.

This study is important because it addresses a key issues that is seen in patients with rheumatoid arthritis, increased cardiovascular risk and investigates a possible mechanism to mitigate that risk. The article notes that "RA patients have a 60 % increased risk of death from myocardial infarction and
stroke and a 48 % increased risk of incident myocardial infarction, which is a staggeringly large percent in a population already struggling with their health and thought to be related to the increased levels of homocysteine in the body.
One key finding of this review is that in the majority of prospective studies done, folic acid (an essential vitamin) was found to decrease the levels of homocysteine in the body when used with patients taking methotrexate, a DMARD which commonly causes hyperhomocysteinemia.
The clinical implications of this review are that with the supplementation of a single vitamin, there is potential to reduce the risk of cardiovascular disease and death from MI/CVA by almost half. Folate supplementation can be prescribed as a medication, but it can also be obtained from folate-rich foods such as green leafy vegetables and many legumes.

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Citation:
Pocovi-Gerardino G, Correa-Rodríguez M, Callejas-Rubio JL, Ríos-Fernández R, Martín-Amada M, Cruz-Caparros MG, Rueda-Medina B, Ortego-Centeno N. Dietary Inflammatory Index Score and Cardiovascular Disease Risk Markers in Women with Systemic Lupus Erythematosus. Journal of the Academy of Nutrition and Dietetics, Volume 120, Issue 2, 2020,Pages 280-287, ISSN 2212-2672, https://doi.org/10.1016/j.jand.2019.06.007.

Why is this study important?

This study is important because it brings to light that patients with Systemic Lupus Erythematosus (SLE) have a higher risk of developing cardiovascular disease than the general population.   The authors of this study point out that currently, cardiovascular disease is the leading cause of death in patients with SLE. As practitioners it is important not to forget that although nutrient deficiencies such as Vitamin D and protein may exist and anemia is a common challenge of patients with lupus that practitioners should address the benefits of a cardioprotective lifestyle (which includes anti-inflammatory dietary pattern) for patients with lupus.

Identify one key finding of this study and describe how it relates to nutritional science.

A pro-inflammatory diet is associated with less than favorable serum lipid profiles in patients with SLE.

What are the clinical implications of this study?

The study included 105 women with SLE and attempted to investigate the relationship between a proinflammatory diet and cardiovascular disease risk.  Patients with SLE are at a high risk for cardiovascular disease and the authors of this study suggest that an anti-inflammatory dietary pattern may play a role in cardiovascular disease management in patients with SLE.  On a personal note, I was very glad to have read this research article because I was not aware that patients with SLE were at higher risk for developing cardiovascular disease and therefore a cardio-protective dietary pattern and lifestyle modification strategies should be included as part of the disease management process for patients with SLE.

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Citation:
Guan Y, Hao Y, Guan Y, Bu H, Wang H. The Effect of Vitamin D Supplementation on Rheumatoid Arthritis Patients: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2020 Oct 30;7:596007. doi: 10.3389/fmed.2020.596007. PMID: 33195358; PMCID: PMC7661491.

This is a very recently published  meta-analysis and systemic review of  6 randomized controlled trials  involving n=438 human subjects diagnosed with  rheumatoid arthritis with intent of evaluating the therapeutic effect of vitamin D supplementation.
This is an important concept because the  effects of  Vitamin D on pathophysiology of the immune system as it relates to rheumatoid arthritis, including regulating T-cell activity is understood.  However, it is not well known how Vitamin D supplementation correlates to symptomatic improvement or improvement in  serologic markers for RA.

The study identified no significant  difference in ESR and CRP levels between control groups and those who received supplementation.  Symptomatically , though, patients who  received vitamin D supplementation reported less RA activity than  the control groups, based on DAS28 (disease activity score for RA).  Symptom scores were positively correlated to  higher dose Vit D and longer time of supplementation.
Clinical Implications:
This is  important  clinical information because of the tremendous impact RA has on quality of life as relates to symptoms, especially chronic pain and physical activity.
While Vitamin D  is  easily accessible and affordable, none of these studies took into account  baseline Vit D status prior to supplementation which I feel  would be  useful  information considering its (albeit rare) potential for toxicity.

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This study is important because it looks at fatigue levels in multiple sclerosis patients (the most common complication) and how nutrition can combat it. Fatigue is an important topic of discussion in MS patients, because the pathophysiology that results in patient fatigue is not yet known. Nutritional studies are at the frontline in helping patients overcome this specific complication. This study was a 2-year dietary analysis on patients that were diagnosed with relapsing remitting sclerosis (RRMS) using nutritionist IV computer software program. This study found that in patients experiencing fatigue symptoms after MS diagnosis were meeting caloric energy requirements from macronutrients but found that there was a significantly lower level of micronutrient consumption compared to DRI. Most importantly, patients with the highest fatigue scores showed levels of magnesium and folate were below DRI. This has nutritional implications in that patients can adjust their diet to increase magnesium and folate levels to DRI. Foods such as seed and nuts, and avocado are high in both micronutrients and can help decrease fatigue in MS patients. Because fatigue is the most common and problematic symptom in patients that are diagnosed with MS, nutritional studies (low levels of magnesium and folate in this study) can provide a way to possibly increase the quality of life in these patients. Bitarafan, S., Harirchian, M. H., Nafissi, S., Sahraian, M. A., Togha, M., Siassi, F., Saedisomeolia, A., Alipour, E., Mohammadpour, N., Chamary, M., Honarvar, N. M., & Saboor-Yaraghi, A. A. (2014). Dietary intake of nutrients and its correlation with fatigue in multiple sclerosis patients. Iranian journal of neurology, 13(1), 28–32.

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Citation: Jorge Correale & Andrés Villa (2007) The blood–brain-barrier in multiple sclerosis: Functional roles and therapeutic targeting, Autoimmunity, 40:2, 148-160, DOI: 10.1080/08916930601183522

Before discussing the paper this week, I wanted to mention that in our weekly reading paper “Pathogenesis and epidemiology of multiple sclerosis” it was mentioned that patients with inflammatory bowel diseases have an increased risk for demyelinating diseases, including MS. In the paper I chose for my Weekly Wall last week, it was indicated that inflammatory bowel diseases open the blood-brain barrier. Since it is speculated that T-cells cross the blood-brain barrier and activate an immune response that leads to demyelination, one could hypothesize that inflammatory bowel diseases allow the BBB to open enough for T-cells to begin crossing into the brain.

This study is relevant to the above information because it reviewed how different situations could lead to the BBB opening and thus play a part in MS and how potentially treating these different targets could become effective therapeutic strategies. Specifically, I want to focus on their review of how MMPs (proteolytic enzymes involved in extracellular matrix remodeling) play a role in disease progression. The study discusses how MMPs cause degradation of the basement membrane and opens the BBB. Among MS patients there is an increased expression of certain MMPs found in CNS lesions. It has also been discovered that in patients with IBD, MMP expression is also upregulated (link below) which could explain why IBD patients have an increased risk for MS.

These findings could have important clinical implications. For example, the review discusses how minocycline can reduce MMP-9 activity and this has shown to significantly reduce the number of MRI-enhancing lesions in MS patients. It also has implications that having patients follow the general diet recommendations for IBD can lower their risk of developing MS.

https://www.hindawi.com/journals/mi/2015/964131/

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Dietary Omega Polyunsaturated Fatty Acid Intake and Patient‐Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program

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Dietary Omega Polyunsaturated Fatty Acid Intake and Patient‐Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program

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Citation: Charoenwoodhipong, P., Harlow, S.D., Marder, W., Hassett, A.L., McCune, W.J., Gordon, C., Helmick, C.G., Barbour, K.E., Wang, L., Mancuso, P., Somers, E.C. and Zick, S.M. (2020), Dietary Omega Polyunsaturated Fatty Acid Intake and Patient‐Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program. Arthritis Care Res, 72: 874-881. https://doi.org/10.1002/acr.23925

Systemic lupus erythematosus is an autoimmune disease associated with substantial comorbidities and diminished quality of life. This study addresses non-pharmacologic interventions in treating persistent symptoms including fatigue, poor sleep, chronic pain, depression, with modification of dietary polyunsaturated fatty acid (PUFA) intake.

The study showed that lower dietary intake levels of omega-6 (proinflammatory) FA and higher dietary intake levels of omega-3 (antiinflammatory) FA are favorably associated with patient-reported outcomes in lupus, including decreased lupus activity and better sleep quality. It's found that low serotonin levels result in sleep disruption and sleep disorders. In this case, EPA and DHA blood levels may be influencing an increase in serotonin level. As such, higher DHA levels and oily fish consumption were significantly associated with improved sleep quality and inversely associated with severity of obstructive sleep apnea.

This study prompt health care providers to consider dietary approach to promote intake of fatty fish, nuts, seeds, thus, encouraging a better balance of fatty acids from dietary sources. The finding that dietary intake levels of omega-6 and omega-3 FAs appeared to opposed one another, suggests that use of supplements alone might be less likely than a broader dietary approach to influence patient-reported outcomes in lupus. Given SLE requires multiple pharmacologic agents, an addition of dietary intervention in simultaneously targeting comorbidities is a particularly attractive approach.

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Citation: Dourado E, Ferro M, Sousa Guerreiro C, Fonseca JE. Diet as a Modulator of Intestinal Microbiota in Rheumatoid Arthritis. Nutrients. 2020;12(11):3504. Published 2020 Nov 14. doi:10.3390/nu12113504

The aim of this paper was to look at the Mediterranean Diet (MD) and its possible effect on the microbiota of patients with rheumatoid arthritis (RA). Although this paper does not provide definitive "proof" that the MD is the absolute answer is does provide valuable information on the science behind how the microbiota is affected by the types of food eaten regularly.

Some interesting take-home points are summarized by the authors. Lack of sufficient dietary fiber (especially fermentable fiber) leaves the microbiota unable to provide enough short chan fatty acids (SCFA) as an energy source for the gut epithelial cells. If the gut epithelial cells are short on energy they lack the tight juntions and barrier function declines which as we learned in the GI module sets the inflammatory cascade into overdrive. The discussion on polyunsaturated fatty acids (PUFAs) describes how an inclusion of more n-3 PUFAs (in oily fish, poultry, and nuts) versus n-6 PUFAs (higher in vegetable oils, and meats) enhances the production of anti-inflammatory cytokines. The section on polyphenols (in plant-based foods and beverages, including olive oil, fruits, vegetables, and red wine) and monounsaturated fatty acids (MUFAs)(in nuts and olive oil) show how they increase production of SCFA improving gut integrity. An analysis of fermented foods and probiotics support the use of both to improve production of SCFA to support gut integrity and ultimately less froduction  of pro-inflammatory cytokines.

The Mediterranian diet is high in n-3 PUFAs,  polyphenols, and fiber, but the Standard American diet and the Western diet are high in n-6 PUFAs and saturated fat and low in fiber and n-3 PUFAs. In the end, this paper gives enough compelling support for a healthcare professional to encourage patients with RA to adopt the MD with addition of fermeted foods and probiotics as a complement to their medication regimen.

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Citation: Saresella M, Mendozzi L, Rossi V, Mazzali F, Piancone F, LaRosa F, Marventano I, Caputo D, Felis GE, Clerici M. Immunological and Clinical Effect of Diet Modulation of the Gut Microbiome in Multiple Sclerosis Patients: A Pilot Study. Front Immunol. 2017 Oct 25;8:1391. doi: 10.3389/fimmu.2017.01391. PMID: 29118761; PMCID: PMC5661395.

Key study question: Immune modulation of the gut microbiota through dietary components like fiber could be used to obtain beneficial outcomes in patients with multiple sclerosis

Key study finding: This was a pilot study involving two groups of clinically similar relapsing-remitting (RR) MS patients who had undergone either a high-vegetable/low-protein diet (HV/LP diet group; N = 10) or a “Western Diet” (WD group; N = 10) for at least 12 months.

Gut microbiota analysed after 12 months of diet showed that in the HV/LP diet group (1) Lachnospiraceae family was significantly more abundant; (2) IL-17-producing T CD4+ lymphocytes (p = 0.04) and PD-1 expressing T CD4+ lymphocytes (p = 0.0004) were significantly decreased; and (3) PD-L1 expressing monocytes (p = 0.009) were significantly increased. Lachnospiraceae was observed to favor Treg differentiation as well as TGFβ and IL-10 production.

Clinical implications:

The relapse rate during the 12 months follow-up period and the Expanded Disability Status Scale score at the end of the study period were significantly reduced in those with HV/LP diet. A high vegetable diet, rich in fiber may be beneficial in reducing relapses by improving the gut microbiota and, in turn promoting an anti-inflammatory state.