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Can What You Eat Help Fight Autoimmune Disease?

One of the most frequent questions I’m asked at autoimmune patient forums is about diet, anti-inflammatory foods, and autoimmunity.

There’s a lot of popular pseudo-science out there claiming that the right diet can “cure” autoimmune disease. Much of the “evidence” I’m asked about is anecdotal, largely based on reports of how patients were helped – or not – by eating -- or not eating -- certain foods (notably gluten). It’s difficult to argue with success stories and equally difficult to prove real cause and effect.

However, there’s plenty of solid scientific evidence to support the idea of an anti-inflammatory diet.

Much of what we know about the relationship between diet and inflammation comes from studies about the effects of the Mediterranean diet (and its components) in reducing inflammatory markers in cardiovascular disease (CVD)1 – a well-established risk in autoimmune diseases including rheumatoid arthritis (RA), lupus, and inflammatory bowel disease.

The Mediterranean diet encompasses many anti-inflammatory foods, notably omega-3 fatty acids found in olive and other oils, cold-water fatty fish (like salmon, mackerel, and sardines), nuts, and flax seeds. Olives and olive oil also contain compounds that act similarly to non-steroidal anti-inflammatory drugs (NSAIDs).2 Additionally, the diet includes lots of fresh fruits and vegetables rich in anti-inflammatory plant chemicals.

The diet has been shown to lower inflammatory markers in blood tied to both CVD and autoimmune diseases, including C-reactive protein (CRP), interleukins,and tumor-necrosis factor alpha (TNF-α).1 Studies also show that it helps reduce pain, joint swelling, and other symptoms of RA and other autoimmune diseases – and has beneficial effects on the immune system itself (such as moderating T-cell activity).3

It’s been suggested for years that our “Western” diet high in saturated fats and red meat may not only play a role in CVD but also in autoimmune diseases.4 Indeed, in one study, RA patients assigned to a Mediterranean diet showed a reduction in inflammatory activity and an increase in physical function compared to those assigned to a “Western” diet. 5


•Fatty Fish & Omega 3's

Of all inflammation fighting foods in the Mediterranean diet, we know the most about fatty fish and fish oil, which contain the omega polyunsaturated fats (PUFAS) eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA).

As far back as 1991, researchers suggested that the omega-3 fats in fish may help reduce disease severity in lupus.6 More recently we’ve learned that omega 3’s may help protect against RA. A prospective study of more than 32,000 older Swedish women in 2013 found that eating one or more servings of fatty fish a week was associated with a 29% lower risk of developing RA and long-term intake of high-dose fish oil decreased the risk of RA by 52%).7

A recent British review reported that eating more fish high in omega-3s modestly reduced joint swelling, pain and morning stiffness in RA, leading to less use of NSAIDs.8 A randomized, controlled trial in people with early RA found that around 40% of those given high-dose fish oil to take with their conventional disease modifying anti-rheumatic drugs DMARDs)were in remission after a year.9

However, fairly high amounts of fish oil are needed to achieve an effect (about 3 grams of EPA and DHA in a concentrated fish oil supplement). Fish oil is also an anticoagulant and doesn’t agree with everyone.10 So consult your doctor before adding it to your diet.

Other types of omega-3 fats can be are found in olives, flax seeds, pumpkin seeds and walnuts.

•Olives & Olive Oil

Certain anti-inflammatory properties in olives and olive oil may be a big reason why the Mediterranean diet helps in autoimmune diseases.

Olives and virgin olive oil have been found to contain a polyphenol compound called oleocanthal, which blocks production of the pro-inflammatory enzymes and cyclooxygenase-2 (COX-1 and COX-2) much as NSAIDs do. In fact, research shows oleocanthal has properties similar to ibuprofen.11

The fruit of the olive tree, Olea europaea, also contains oleic acid, a monounsaturated fatty acid which also helps modulate the immune system.12

Olive oil, as well as nuts, sunflower and flax seeds, and avocados are also packed with vitamin E, which helps prevent cell damage in joints and may have anti-inflammatory properties as well.

•Fresh Fruits & Vegetables

The Mediterranean-style diet includes plenty of fresh fruits, vegetables, and beans rich in fiber plus inflammation-fighting plant chemicals (phytochemicals) and antioxidants such as vitamin A, beta carotene, vitamin E, zinc and selenium.

In particular, raspberries and cherries are packed with antioxidants called anthocyanins and vegetables containing flavonoids like onions and garlic are thought to regulate expression of key inflammatory enzymes.

•Green Tea

I meet many autoimmune patients who swear by green tea, which is a good source of antioxidant polyphenols.

Its active ingredient, epigallocatechin-3-gallate (EGCG), has been shown to improve symptoms and reduce the pathology in some animal models of autoimmune diseases.

The effects of EGCG help suppress production of autoreactive T cells and also pro-inflammatory cytokines (such as interleukin-1).13 A recent study showed that EGCG improved rheumatoid arthritis in mice, while another showed effects in lab rats. But there’s an unfortunate lack of research in humans for this healthy beverage.


There are a number of experts who claim that any anti-inflammatory diet must exclude gluten.

There’s no question that gluten, a naturally-occurring protein in wheat, barley and rye, causes celiac disease in genetically susceptible individuals. Gluten triggers an autoimmune inflammatory reaction that damages the small finger-like projections in the small intestine (villi) which absorb many nutrients.

The only treatment for celiac disease is eliminating gluten. It can stop the symptoms of chronic diarrhea, stomach pain, bloating, and gas and help repair damage to the villi. Intestinal healing can take three to six months in children and several years in adults, according to the National Institutes of Health.14

Some people are allergic to wheat or have non-celiac gluten sensitivity and experience severe GI symptoms. While neither problem damages the small intestine, for these people going gluten-free also makes sense.

What’s not so clear is gluten’s effects elsewhere in the body (like the brain) and whether going gluten-free helps other autoimmune diseases, prevents or even “cures” them.

“There is no evidence that a gluten free diet helps autoimmune diseases such as Hashimoto's thyroiditis. Celiac disease is the one autoimmune disease that is appropriate for the gluten-free diet,” Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University told me in an email. “It is as though celiac disease has given the gluten-free a medical legitimacy that other diet trends lack.”

As a result of what he terms a “media epidemic,” “almost a third of all American and UK consumers are trying to avoid gluten,” many of them unnecessarily, he writes in a new book, “Gluten Exposed,” (2016, William Morrow, NY).15


Any elimination diet can have adverse effects, Dr. Green adds, cutting out crucial nutrients such as fiber and essential vitamins and minerals.

The Arthritis Foundation, the Sjögren’s Syndrome Foundation, and other organizations, report that studies since the 1990s have found vegetarian diets to be beneficial for some autoimmune patients. However, you need to get plenty of plant protein from legumes and beans, among other things.

A vegan diet -- which excludes meat, fish, dairy or other animal products -- may also be helpful, possibly because of the types of polyunsaturated fatty acids included in the diet, say British arthritis researchers.10

However, if you go vegan make sure you get vital nutrients you need, especially calcium, vitamin B12, vitamin D, zinc, and selenium.


1 Giugliano D, Ceriello A, and Esposito K, The Effects of Diet on Inflammation. Journal of the American College of Cardiology. 2006;48(4):677–85. doi:10.1016/j.jacc.2006.03.052.

2 Rahmani AH, Abutti AS, and Ali SM. Therapeutics role of olive fruits/oil in the prevention of diseases via modulation of anti-oxidant, anti-tumour and genetic activity. Int J Clin Exp Med. 2014. 7(4 ):799-808. PMCID: PMC4057827. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057827/ Accessed July 20, 2016.

3 Shepshelovich D and Shoenfeld Y.Prediction and prevention of autoimmune diseases: additional aspects of the mosaic of autoimmunity. Lupus. 2006. 15(3):183-190. doi: 10.1191/0961203306lu2274rr s

4 Manzel A, Muller DN, Hafler DA et al., Role of “Western Diet” in Inflammatory Autoimmune Diseases. Curr Allergy Asthma Rep. 2014;14:404. DOI 10.1007/s11882-013-0404-6.

5 Sköldstam L, Hagfors L, Johansson G. An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis. Ann Rheum Dis. 2003;62:208–214.

6 Walton AJ, Snaith ML, Locniskar M, et al. Dietary fish oil and the severity of symptoms in patients with systemic lupus erythematosus. Ann Rheum Dis. 1991; 50:463–466.

7 Di Giuseppe D, Wallin A, Bottai M, et al., Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women. Ann Rheum Dis. 2014 Nov;73(11):1949-53. doi: 10.1136/annrheumdis-2013-203338.

8 Miles EA, Calder PC, Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis. Br J Nutr. 2012 Jun;107 Suppl 2:S171-84. doi: 10.1017/S0007114512001560.

9 Proudman SM, James MJ, Spargo LD, et al. Fish oil in recent onset rheumatoid arthritis: a randomised, double-blind controlled trial within algorithm-based drug use. Ann Rheum Dis. 2015. 74:89-95 doi:10.1136/annrheumdis-2013-204145.

10 Arthritis Research UK, Diet and Supplements. http://www.arthritisresearchuk.org/arthritis-information/complementary-and-alternative-medicines/complementary-therapies/diet-and-supplements.aspx#sthash.g3ajjiyB.dpuf Accessed July 19, 2016.

11 Lucas L, Russell A, Keast R. Molecular mechanisms of inflammation. Anti-inflammatory benefits of virgin olive oil and the phenolic compound oleocanthal. Curr Pharm Design. 2011;17(8):754–68. DOI: 10.2174/138161211795428911. http://www.ncbi.nlm.nih.gov/pubmed/21443487 Accessed July 19, 2016.

12 Sales-Campos H, Souza PR, Peghini BC, et al., An Overview of the Modulatory Effects of Oleic Acid in Health and Disease. Mini Reviews in Medicinal Chemistry. 2013;13(2):201-210. DOI: 10.2174/13895575113130220003.

13 Wu D, Wang J, Pae M, Meydani SN. Green tea EGCG, T cells, and T cell-mediated autoimmune diseases. Mol Aspects Med. 2012 Feb;33(1):107-18. doi: 10.1016/j.mam.2011.10.001. Epub 2011 Oct 14. http://www.ncbi.nlm.nih.gov/pubmed/22020144. Accessed July 19, 2016.

14 Treatment for Celiac disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/celiac-disease/Pages/treatment.aspx Accessed July 19, 2016.

15 Green PR, Jones R. “Gluten Exposed: The Science Behind the Hype and How to Navigate A Healthy, Symptom-Free Life,” (2016, William Morrow, NY).

16 The Arthritis Foundation: Eat Right for Your Type of Arthritis. http://www.arthritis.org/living-with-arthritis/arthritis-diet/anti-inflammatory/eat-to-beat-inflammation.php Accessed July 19, 2016
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What We can All Learn from Venus Williams

OK. I admit it: I’m a major Venus Williams fan. Actually, I root for Venus and Serena.

Watching Venus power through moments of fatigue, both mental and physical, on the tennis court is always inspiring for me. Not just because of her consummate skill, elegant play, and powerful serve (not to mention her campaign on behalf of equal pay for women in tennis), but also because she’s living with an autoimmune disease that takes a toll on body and spirit.

When Venus revealed in 2011 that she had Sjögren’s syndrome, many people expected her to retire from tennis. The fatigue and joint pain that accompanies Sjögren’s and many other autoimmune diseases can be debilitating for anyone -- even for a star athlete.

“It’s been a journey, but it’s something that I had to do. And it’s made me stronger,” Venus remarked after defeating Yaroslava Shvedova in straight sets July 4th in the Wimbledon quarter-finals. “The most difficult part of the journey is just not being in control because when you’re an athlete, you’re used to being in control, being able to work for anything. Not being able to do that is a challenge,” she said during a post-match press conference.1

Primary Sjögren’s syndrome, the result of an autoimmune attack on moisture-producing tissues, is 10 times more common in women than in men, possibly affecting as many as 3.1 million Americans. That prevalence doubles in secondary Sjögren’s, coupled with other autoimmune and connective tissue diseases.2

An online survey of nearly 8,000 patients by the American Autoimmune Related Diseases Association (AARDA) in 2015 found that 98% experience fatigue that many describe as “profound,” preventing them from doing even the simplest of everyday tasks.3 At least 60% to 70% of women with Sjögren’s are beset by fatigue.4

On July 7, the Sjögren’s Syndrome Foundation (SSF) issued the first-ever U.S. clinical guidelines for managing the disease, including fatigue.2 In those guidelines, the SSF continues to recommend aerobic exercise for fatigue (details below).

A Difficult Diagnosis

Sjögren’s can be difficult to diagnose -- especially in cases like Venus Williams', when fatigue, painful swollen joints and shortness of breath are the most noticeable symptoms -- rather than the hallmark dry eyes.

Venus was initially told she had exercise-induced asthma. “I’d go to doctors, but I never got any answers, so there was nothing I could do but keep going,” she told the New York Times in 2011.5 “It was frustrating, always being in the dark and not having anything to help me but my own will.”

That’s an experience shared by millions of women with autoimmune diseases.

Data from AARDA show that among autoimmune diseases, Sjögren’s syndrome takes the longest time to diagnose – 6.5 years of multiple doctor visits. And almost 60% of Sjögren’s patients are told their disease was “imagined” or they were just being “overly concerned.”6

When a diagnosis finally comes, it’s a relief, patients often remark. At least you know what you’re up against and that you’re not crazy.

What Treatments Help?

Problem is, all FDA-approved treatments for Sjögren’s target dry eye, dry mouth and other signature “sicca” symptoms, but none are aimed at alleviating fatigue or joint pain.

A recent review from the division of rheumatology and immunology at Duke University notes that new drug development has focused on ways to modulate the immune system and dampen chronic inflammation. But “other mechanisms may be at play, such as neuroendocrine abnormalities, that affect some of the disease manifestations, such as fatigue,” and could be potential targets for therapy.7 At this stage, the Duke reviewers note “no disease-modifying drugs have been shown in randomized, placebo-controlled trials to be effective for the treatment of primary Sjögren’s syndrome.”7

While the anti-malarial hydroxychloroquine (Plaquenil) has been used to reduce fatigue and joint pain in primary Sjögren’s, a randomized controlled trial reported in 2014 that the oral drug “failed to “failed to significantly reduce symptoms of dryness, pain, and fatigue over placebo.”7

More recently, biological drugs -- the tumor necrosis factor (TNF) inhibitors infliximab (Remicade and etanercept (Enbrel) -- have been investigated for their efficacy and safety in patients with primary Sjögren’s syndrome. But neither was found to be effective for improving disease outcomes.8, 9

And the new clinical treatment guidelines from the SSF, published online in Arthritis Care & Research strongly recommend against the use of biologics for any aspect of Sjögren’s.2

However, the SSF says hydroxychloroquine, may be considered as an option for treating fatigue – a recommendation largely based on patient experience (in one study 1/3 of patients found it helpful).2 Even though the evidence for its use against fatigue is weak, the SSF notes that hydroxychloroquine is a safe medication.4

The guidelines do recommend hydroxychloroquine as the first-line treatment for musculoskeletal pain in Sjögren’s and, if that’s not effective, methotrexate may be added.

Short-term low-dose corticosteroids may also be tried if that approach isn’t helpful, with longer-term higher doses as an option.2

Other conventional disease modifying anti-rheumatic drugs (DMARDs), such as leflunomide (Arava) and sulfasalazine can be considered. (Venus is taking medications for her Sjögren’s.)

Fighting Fatigue

So what can you do about fatigue?

The SSF guidelines, drafted by a panel of experts with input from Sjögren’s patients, recommend daily exercise as an effective way to fight fatigue, citing a number of clinical trials (considered the gold standard of medical research) that found exercise an effective fatigue fighter.2

The SSF generally recommends women gradually work up to 25 minutes a day of aerobic exercise (and, no, you needn’t play tennis!).9

Other ways to fight fatigue from the SSF: pacing yourself and not taking on too much, giving yourself a 20-minute "time-out" every few hours, and getting enough sleep.9

Some women have found adopting an “anti-inflammatory” diet helps reduce joint pain and fatigue. Venus says she juices twice daily, and eats raw, unprocessed, vegan foods.

Another approach is to imitate the diet purportedly eaten by our prehistoric ancestors – meat, fish, vegetables and fruit, but no dairy, grain, or processed foods – often dubbed the “Paleo” diet. But there's no real evidence that it works. (We’ll talk about diet and anti-inflammatory foods in a future post.)

Other advice to combat fatigue from the SSF: pacing yourself and not taking on too much, giving yourself a 20-minute “time out” every few hours, and getting enough sleep.9

But sometimes the fatigue can be too much.

In “The Autoimmune Connection,” we quoted Sjögren’s patients who said that when fatigue hit “the body can stiffen up, become painful, and feel as if it had ‘run out of energy,’ ‘given up,’ or ‘had flat batteries,’ forcing them to put their life on hold.”10

Indeed, Venus briefly curtailed play after dropping out of the U.S. Open in 2011 because of fatigue and back pain. “The fatigue is hard to explain unless you have it,” Williams remarked at the time.5 “Some mornings I feel really sick, like when you don’t get a lot of sleep or you have a flu or cold. I always have some level of tiredness. And the more I tried to push through it, the tougher it got,” she told the New York Times.

But her passion for the game and her determination to win ultimately propelled Venus back into the game. Both qualities were on ample display at Wimbledon, both in her victory over Shvedova as well as in her defeat by Angelique Kerber in the semis July 8.

The very next day, she and sister Serena went on to win their 14th Grand Slam doubles match -- just a couple of hours after Serena captured her 22nd Grand Slam singles title against Kerber.

“It’s easy to be afraid. You have to let fear go,” Venus told the press at Wimbledon earlier in the tournament. “You’ve got to believe in yourself. No matter how things are stacked against you, you just have to every time.”1

Venus Williams defeated on the court? Occasionally. Defeated in life. Never.

That’s a lesson we can all learn -- even if we’re not tennis champs.


1 Venus Williams: Quarter Final. The Championships, Wimbledon 2016. Wednesday, 6 July 2016. http://www.wimbledon.com/en_GB/news/articles/2016-07-06-/venus_williams_quarterfinal.html

2 Carsons SE, Vivino, FB, Parke A, et al., Treatment Guidelines for Rheumatologic Manifestations of Sjögren’s : Use of Biologics, Management of Fatigue and Inflammatory Musculoskeletal Pain. Arthritis Care and Research. 2016; Jul 7. doi: 10.1002/acr.22974. [Epub ahead of print]. http://onlinelibrary.wiley.com/doi/10.1002/acr.22968/abstract. Accessed July 8, 2016.

3 American Autoimmune Related Diseases Association, Autoimmune Patient Survey on Fatigue, Released March 23, 2015. http://www.aarda.org/wp-content/uploads/2015/03/EMBARGOED+PressReleaseFatigueSurvey.pdf
4 Mengshoel AM, Norheim KB, Omdal R. Primary Sjögren’s syndrome: fatigue is an ever present,
fluctuating, and uncontrollable lack of energy. Arthritis Care & Research. 2014;66(8):1227–1232. doi:10.1002/acr.22263.

5 Crouse, K. Williams Says She Struggled With Fatigue for Years. New York Times, September 1, 2011.

6 American Autoimmune Related Diseases Association/National Coalition of Autoimmune Patients Survey Data, 2014.

7 Holdgate N and St. Clair WE. Recent advances in primary Sjögren’s syndrome. Version 1. F1000Res. 2016; 5: F1000 Faculty Rev-1412. Published online 2016 Jun 17. doi: 10.12688/f1000research.8352.1 PMCID: PMC4916986. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916986/ Accessed July 4, 2016.

8 Gottenberg JE, Ravaud P, Puéchal X, et al. , Effects of hydroxychloroquine on symptomatic improvement in primary Sjögren syndrome: the JOQUER randomized clinical trial. JAMA. 2014;312(3):249–58. 10.1001/jama.2014.7682.

9 “Fatigue Fighters in Sjögren’s,” January 16, 2014. The Sjögren’s Syndrome Foundation, http://info.sjogrens.org/conquering-sjogrens/bid/331597/Fatigue-Fighters-in-Sj-gren-s

10 Baron-Faust R, Buyon JP. “The Autoimmune Connection, 2nd Edition,” 2016, McGraw-Hill, NY. Page 177.
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