Plant-based dietary changes may improve symptoms in patients with systemic lupus erythematosus

Introduction Previous studies have reported that patients affected by systemic lupus erythematosus (SLE) are interested in using diet to treat fatigue, cardiovascular disease and other symptoms. However, to date, there is insufficient information regarding the ways for patients to modify their diet to improve SLE symptoms. We investigated the relationship between the eating patterns of SLE patients and their self-reported disease symptoms and general aspects of health. Methods A UK-based, online survey was developed, in which patients with SLE were asked about their attitudes and experiences regarding their SLE symptoms and diet. Results The majority (>80%) of respondents that undertook new eating patterns with increased vegetable intake and/or decreased intake of processed food, sugar, gluten, dairy and carbohydrates reported benefiting from their dietary change. Symptom severity ratings after these dietary changes were significantly lower than before (21.3% decrease, p<0.0001). The greatest decreases in symptom severity were provided by low/no dairy (27.1% decrease), low/no processed foods (26.6% decrease) and vegan (26% decrease) eating patterns (p<0.0001). Weight loss, fatigue, joint/muscle pain and mood were the most cited symptoms that improved with dietary change. Conclusion SLE patients who changed their eating patterns to incorporate more plant-based foods while limiting processed foods and animal products reported improvements in their disease symptoms. Thus, our findings show promises in using nutrition interventions for the management of SLE symptoms, setting the scene for future clinical trials in this area. Randomised studies are needed to further test whether certain dietary changes are effective for improving specific symptoms of SLE.


Lay Research Summary
How you can help influence a new research proposal.
We are a group of researchers at University College London (UK) studying patients with Lupus. We want to increase our understanding of what causes the disease so that we can improve and develop new treatments for patients. We have a new and exciting idea that we believe could help to reduce disease severity. Before we start this project, we would like to find out from you whether you have any experiences that could help us improve our research.
We are interested in how diet can influence the immune system (the body's natural defense system). We have found that certain foods are linked with harmful inflammation in the body and disease flares. We would like to find out whether altering the diet could have a beneficial effect on Lupus by decreasing inflammation. Therefore, greater knowledge of how diet has affected patient experience with Lupus would help us understand the potential of this new idea. We hope this approach could reduce the dependence of patients on drugs.
Before we begin this research, we would like to ask you some short questions to help us understand your experience with diet and Lupus. Your input is of huge value to our research. Please click "Next" below to answer these questions.
All of us at UCL Centre for Rheumatology Research would like to extend a grateful thank you for your time and support in answering these questions; it is only together we can really make progress in understanding this disease. By completing this questionnaire, you are consenting to us sharing your responses. All of your answers will be completely anonymous.

Supplementary Data
Free-text responses to: How did you change your eating habits? Please explain. 1. Changed to a low carb diet 2.
Restricted red meat and cut out spicy and acidic foods. Also omitted fizzy drinks. 3.
Saw a nutritionist who prescribed an exclusion diet and used paleo diet -gluten free dairy free plus plenty of good protein omega 3 leafy green vegetables. I kept a food diary. Avoided bought gluten free foods as full of additives and sugar. I avoided sugar and this significantly reduced inflammation 4.
Avoid eating mushrooms. Take meal replacements protein shake for dinner to reduce food intake 5.
By avoiding certains kinds of food and adding more of others. 6. fasting 7.
Cut out carbs completely and all meat except fish. 9.
Generally eat a mediterranean diet. Lowered levels of processed foo 10.
Went on the autoimmune protocol 11. cut out alcohol& caffiene reduced sugar content 12.
Reduced sugar and carbohydrate intake. 14.
Gluten free more plant based less processed foods 15.
Eating more healthy, less fatty foods 16. Tried Gave up meat and processed foods. Just trying to become more healthy and balanced all round 70.
I try to avoid immune system boosting foods 72.
Vegetarian for health and ethical reasons, avoid garlic and alfalfa sprouts because they trigger lupus flares. I limit processed sugar and white flour. 73.
Had pancreatitis a few times because of lupus and pbc, so keep to a low fat diet, avoid spicy foods 75.
Green smoothies and trying to eat a Plant base diet 76.
Avoided buying junk food and processed foods often and cooking more rather than eating out/or ordering takeout 77.
Changed to a vegetarian diet with limited process foods 78. Low

Mechanism 1 Weight loss
High intake of fibre and water reduces the caloric density of the overall diet while increasing satiety and energy expenditure (1). Resultant decrease in white adipose tissue (WAT), an active and inflammatory organ that releases adipokines, which are molecules that contribute to inflammation in rheumatic disease (2).

Restricting processed foods, refined carbohydrates and sugar
Commonly used industrial food additives such as gluten, glucose, salt and emulsifiers breach the integrity of the intestinal-epithelial barrier, resulting in entry of foreign immunogenic antigens and activation of the autoimmune cascade (3).
Regular consumption of excess free fructose contributes to intestinal accumulation of advanced glycation end-products that cross the intestinalepithelial barrier and promote inflammation in tissues (4).
High intake of processed foods leads to excess calorie intake and weight gain and is associated with increased biomarkers of inflammation (5-9).

Restricting meat/ animal products
Large intake of ω6-polyunsaturated fatty acids (PUFA), saturated and transfatty acids have pro-inflammatory and aggravating effects for SLE symptoms (10). Moderate protein intake is associated with better immune function and delay in autoimmunity (10,11).

Increasing intake of vegetables, fruit, legumes and wholegrains
Fibre, vitamins, minerals, isoflavones, phytochemicals, PUFA and other plant metabolites have anti-inflammatory effects. Many of these components positively diversify gut microbiota and mediate metabolic, inflammatory and immunity pathways (12).
High dietary fibre improves the synthesis of short chain fatty acids (SCFAs) in the metabolome and decreases the level of harmful free-radicals involved in disease state (13,14).
High intake of ω3 PUFA reduces levels of pro-inflammatory cytokines such as IL-1, IL-6 and TNF (15). ω3 PUFA are also essential for the synthesis of eicosanoids, regulators of the inflammatory cascade (13).
Polyphenols from plants such as flavonoids have anti-inflammatory and antioxidant activity (16).

Mood improvement
Plant metabolites such as phytochemicals boost mood through their serotonergic, noradrenergic and dopaminergic effects (17). ω3 PUFA modulate serotonin receptors in the cortex and hippocampus and increase brain-derived neurotrophic factor (BDNF) expression (17). Vitamin C and magnesium antagonise the activity on N-methyl-D-aspartate (NMDA) receptors and increase BDNF (18,19).
Decrease in pro-inflammatory molecules that negatively impact the circuitry in depression-related brain regions, such as the anterior cingulate cortex, amygdala and insula (20)(21)(22). Table 2. The literature identifies the main mechanisms through which WFPB diets could contribute to decreased inflammation and reduction in symptoms in SLE patients.