Nutrition and Supplements to Reduce Medication Side Effects in Myositis

Healthy eating is an important part of self-care for everyone, but particularly for those who have a chronic disease such as myositis. Good nutrition is especially important in view of some of the medications taken by people with myositis. Appropriate eating, sometimes with the addition of supplements, can help reduce some of the side effects of those medications.

Medications and Possible Side Effects

Corticosteroids (also known as steroids), such as prednisone, may have multiple side effects when taken long term at higher doses. Some side effects of steroid use that may be reduced by nutritional planning (including the DASH guidelines discussed below) are:

• osteoporosis (loss of bone density, which can lead to fractures) risk may be lowered by getting enough calcium and vitamin D through food and/or supplements;
• fluid retention and hypertension (high blood pressure, which can increase your risk of heart attack and stroke), if they occur, may be controlled by eating a diet low in sodium (salt);
• hyperglycemia (steroid-induced diabetes), if it occurs, may benefit from a diet low in sugar and other simple carbohydrates;
• proteinuria (in which your body breaks down protein a little faster than usual), if it occurs, may mean you need to add more protein to your diet;
• weight gain may be minimized by following a healthy eating plan low in saturated fats.

Immunosuppressants, such as methotrexate and cyclophosphamide - as well as high-dose steroids - help myositis by tamping down the responses of the immune system. While this helps prevent the body from attacking itself, it also increases your risk of infection. That's even more reason to have a healthy, well-balanced diet. In addition, methotrexate also impairs your body's ability to absorb folic acid. So it's important to eat foods high in folic acid, such as leafy green vegetables, fruits, and breads/cereals fortified with folic acid. Also discuss with your doctor whether you should take folate supplements.

Non-steroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen, and naproxen (available over the counter) and many more potent ones available by prescription. All may increase your risk of stomach upset, ulcers, and gastric bleeding. Taking enteric aspirin, which is coated to avoid breakdown in the stomach, and taking your NSAID with meals may reduce symptoms. However, if you have stomach upset or pain, tell your doctor, who may prescribe a newer type of NSAID, called a COX-2 inhibitor, which reduces the risk of gastro-intestinal upset.

The DASH Meal Plan

DASH stands for "Dietary Approach to Stop Hypertension," which was the name of a research study to determine whether diet could help control high blood pressure. The results showed that the DASH diet did indeed have results equal to medication in controlling hypertension - and offered the bonus that it helped lower cholesterol levels. DASH is a good, well-balanced eating plan that can help anyone be healthier, and it can be particularly helpful for those with myositis who are taking steroids or immunosuppressants to help manage side effects. The DASH diet also will help with weight management.

DASH has more fruits, vegetables, and low-fat dairy than what many people are used to eating, and it is low in saturated fat and total fat. As a result, it is low in cholesterol, high in dietary fiber, and moderately high in protein.

Many people have difficulty meeting the fruit and vegetables requirements of DASH. Try having fruits as snacks - and carrying them around with you. While drinking fresh fruit juice is adequate, you do miss something by not having the pulp and fiber from eating the actual fruits.

Eating whole wheat bread, whole wheat pasta, whole grain cereals, and brown rice are a good ways to meet your grain requirements.

Remember that 3 oz. (i.e. one serving on the DASH diet) of meat, fish, or poultry is about the size of a deck of cards. Be sure to have fish two or three times a week. Your best choices are those high in omega-3 fatty acids, which may help reduce inflamation. These include salmon, tuna, herring, trout, blue fish, mackerel, sardines, and white fish. However, swordfish and more than three cans of tuna per week may not be healthy due to mercury contamination.

Whenever you are changing your diet, it is wise to start slowly, making gradual changes in your eating habits. For the DASH approach, you need to learn to center your meal around complex carbohydrates, such as pasta, rice, beans, and vegetables, rather than meat.

For more information about the DASH diet, including sample menus, check out this National Institutes of Health website, which provides a useful booklet that you can download as a PDF file.

Other Nutrition Tips

Most people get enough protein from their usual diet. The major exceptions are people who do not eat meat and/or people who are rarely hungry and are, in fact, losing weight. Good protein sources for vegetarians include beans, soy, peanut butter, and dairy products.

Consider adding soy to your diet. Soy protein is equal in quality to that of the protein in animal foods. Adding soy to your diet also increases fiber intake and helps regulate cholesterol levels. It may also help increase bone mass, decrease symptoms of menopause, and may help reduce your risk of heart disease and cancer. However, some research suggests that too much soy is not a good idea if you are at risk for breast cancer, due to its estrogen-like features. Nonetheless, even for people at higher risk for breast cancer or those with hypothyroidism, three servings a week of soy are thought to be quite safe.

Good sources of soy are miso, soybeans, tempeh, edemame, soy milk, tofu, soy hot dogs, soy noodles, and roasted soybeans (a delicious snack and lower in fat than peanuts). If you want to try incorporating tofu into your diet, try it first at a restaurant where they know how to prepare it in a tasty way. Most people don't know how to cook with it and therefore may be unfortunately turned off by initial attempts. Keep in mind that tofu tends to adapt the flavors of seasonings used and foods with which it is cooked. Good tofu recipes and storage tips can be found at www.soyfoods.com.

Nuts are high in protein and fiber and are not the "no-no" many people fear, especially the unsalted types, which are better if you are on steroids. While nuts do have fat in them, they are usually the good kind (monounsaturated fats). Avocados are also high in monounsaturated fats and can help provide variety in textures and tastes in salads.

To further reduce the salt in your diet, strain and rinse canned beans and vegetables before cooking them. Also beware of the high salt content in prepared foods, especially fruits. Check package labels, and look for low sodium foods.

Antioxidant vitamins help protect our cells from inflammation and aging and may help protect us from cancer. The best way to get them is by eating fruits and vegetables. Try to eat a variety of foods every day. Don't follow a strict diet of the same foods all the time; not only does it lead to boredom, but such a regimen may often lack essential nutrients. Try new foods often.

See a nutritionist for a personally tailored diet plan if:

• you are diagnosed with diabetes;
• you have difficulty swallowing and are losing weight;
• you have unintentional weight loss or gain of 10% of your usual body weight; or
• you are diagnosed with osteoporosis.

Hospital for Special Surgery offers outpatient one-on-one nutritional counseling. If you are interested, please call (212) 774-7638.

Balancing Food and Vitamin/Mineral Supplements

Your best source of vitamins and minerals is through food. However, supplements should be used whenever you need to fill a nutrition "gap" between what you need and what you eat. Make sure you know the recommended doses of supplements before you shop for them; avoid overdosing. Your calcium needs vary by age, although people with myositis who are on steroids need at least 1200 mg per day - or 1500 mg if you are 65 or over. At least 400 units a day of vitamin D is needed to enable your body to absorb calcium.

Milk is a particularly good source of nutrients because it has a mix of calcium, potassium, and magnesium that helps build bones and lower blood pressure. If you are lactose intolerant, Lactaid or soy milk are good calcium sources, as are yogurt and cheese. However, yogurt is not fortified with vitamin D; so if you get a large portion of your calcium from yogurt, take a vitamin D supplement.

If your calcium intake is primarily through supplements, be sure to take them in divided doses - with breakfast and dinner - because your body cannot absorb too much calcium at once. For example, if you are taking 1200 mg of calcium a day through supplements, it is best for optimal absorption to take 600 mg in the morning and the remaining 600 mg in the evening.

If you take a daily multivitamin, it is best to take it separately from your calcium supplement - by two to four hours - because the calcium supplement will interfere with your body's absorption of iron in the multivitamin. For this reason, do not take iron and calcium supplements at the same time. Further, it is best not to take more than one multivitamin a day; overdoses can have harmful effects on the liver and kidneys.

Herbal and Other Dietary Supplements and Alternative Therapies

Before taking any herbal or nutritional supplement, get a diagnosis from a physician to find out exactly what medical problem you have. Don't self-diagnose. After discussing traditional therapy with your doctor, spend some time researching any supplement before experimenting with it. Always let your doctors know about any supplement you are considering or already taking so that they can appropriately monitor for potential side effects.

Be very cautious about any herbal supplement or other alternative therapy because these products are not monitored by the Food and Drug Administration. Even if they are safe, the product may not contain the stated amount (or even any) of the supposed active ingredient, or the product may be contaminated with toxic substances. If you are considering such supplements, even any vitamin/mineral, always discuss it with your physician because many such supplements may actually interfere with your prescription medications. If you decide to proceed, use a well-known, reputable brand.

Avoid supplements that promise to boost your immune system, especially herbals such as echinacea. Any substance taken to boost the immune system may counteract drugs you are taking for myositis. Some doctors believe that these supplements can actually cause flares in some autoimmune diseases.

If you feel a cold, flu or other infection coming on, don't self-treat with over-the-counter medications. Call your doctor, especially if you are on high doses of prednisone or are taking some other immunosuppressant. The sooner your doctor starts treatment, the better the outcome.

Many people with myositis have questions about the use of creatine supplements. Our bodies make creatine from the amino acids in protein. Good food sources are herring, cod, beef, pork, salmon, and milk. Vegetarians tend to have lower stores of creatine. The jury is still out on the benefits of creatine supplements to build muscle, and it is generally believed to be harmless. There are several studies going on to evaluate creatine in various types of myositis. However, one side effect of creatine supplements can be decreased kidney function. So be sure to discuss creatine with your doctor before taking it.

Glutamine is a non-essential amino acid that is stored in muscle. It is also found in protein and/or supplements. Research to date does not suggest that increased levels of glutamine are helpful in myositis.

Resources

For further reading on the topic, consider the following:

• The Arthritis Foundation's Guide to Alternative Therapies, by Judith Horstman
• The Health Professional's Guide to Popular Dietary Supplements, by Allison Sarubin
• Food Medication Interactions, 11th edition, by Zaneta M. Pronsky (Write to Food Medication Interactions, PO Box 204, Birchrunville, PA 10421-0204)

About the Myositis Education and Support Group at HSS

posted 10/14/2002

Summary prepared by Wendy Doran, MSW, Coordinator, LupusLine and Charla de Lupus Programs (formerly Myositis Group Facilitator) and Diana Benzaia.