by Janet Segall, IPPF Executive Director
In order for patients with pemphigus and pemphigoid to get control of their disease, there are certain drugs that patients must take. Prednisone is the first drug of choice for treating these diseases. Immunosuppressive drugs are often given as well to help patients reduce the doses of corticosteroids (prednisone/prednisolone).
Prednisone (prednisolone) is one of the most successfully and one of the most commonly used drug for treating a variety of diseases, but it can have many side effects. Some of the effects of long-term steroid use on our health are: weight gain, increased appetite, loss of muscle mass and bone density, increased fatty deposits, reduction in zinc, Vitamin D, and C levels; loss of potassium, fluid retention, gastric problems, hypertension, high cholesterol, and hampering the body’s ability to handle blood sugars.
An important fact to remember, however, is that although there are many problems and side effects that can occur when using steroids (prednisone/prednisolone), not everyone will experience the same ones. As significant as these side effects can be, there are things we can all do nutritionally that might help lower these effects.
The Foundation has published articles in the newsletter on the subject of diet and pemphigus. There are some indications that foods in the Alium group of vegetables (onions, garlic and leeks) might have an effect on triggering pemphigus for some individuals. The researchers add in many other foods that might also be thought of as trigger foods. We suggest that you be aware of these possible trigger foods when picking foods for your diet. It is prudent to remember, though, that most of the connections between diet and pemphigus are theoretical.
Although many of these side effects can be controlled with medication, there are many good foods that might help reduce the devastating effects of steroids.
Potassium is a very important nutrient in maintaining the level of fluid inside a cell. Steroids can deplete potassium. There is a delicate balance between potassium and sodium in and outside the cell that are critical for heart functions, nerve impulse transmission and muscle contractions. Foods high in potassium are: all fruits especially bananas, apricots, prunes, oranges, tomatoes and raisins. Vegetables such as potatoes, artichokes, and spinach as well as squash are also high in potassium. Beans and almonds are good sources as well.
There is some research that indicates that potassium can also help reduce blood pressure. Watch salt intake to reduce blood pressure and reduce fluid retention. Sometimes a person will think that fluid retention is akin to weight gain. Fluid retention can cause weight gain but as steroids are reduced, fluids will usually reduce as well, along with some of the weight gain. Drinking plenty of water and exercising can help with fluid retention.
Weight gain and increase in appetite – Sometimes if you are also taking an immunosuppressive, the appetite might be decreased. Your metabolism is how you burn fat. As you age, your metabolism tends to slow down. Prednisone can have a negative effect on metabolism. Cravings seem to be heightened so drinking water, eating fruits and vegetables can help. Sometimes fruit or vegetable smoothies can fill us up. Protein in the morning (eggs and cheese – flavored soy cheese is good) might help with cravings during the day. Keep some almonds around for to snack.
Loss of muscle mass – Exercise is very important for keeping muscle mass. While on prednisone, try to exercise within your own range. Men have a better chance of building up their muscles after the age of 50 than woman do because of testosterone, but exercise can help woman as well. Proteins (amino acids) are the building blocks of muscles. Protein repairs and builds muscle tissue. Extra corticosteroids in the body can break down amino acids. These amino acids then go and make glucose in the liver instead of building up muscle mass. Eating extra protein (check with the doctor regarding amounts) might help build muscles. Foods high in protein are: fish, eggs, meat, milk, cheese, baked-beans, and soy products. Remember, though, you don’t want to raise your cholesterol so low-fat meats, milk and cheese are recommended. Fish is not only a great source of protein, but also a great source of Omega-3 fatty acids. (check out our article in the Fall 2001 Quarterly [#26] on why Omega-3 fatty acids are important).
A decrease in bone density is extremely common when taking prednisone. Eating extra calcium and taking calcium supplements are very important for anyone taking prednisone. It is known that women and men with thin bones have a higher rate of osteoporosis. It is recommended that everyone get a bone density test when they first start taking prednisone as a baseline for bone density loss. The doctor and nutritionist can advice on the correct amounts of calcium a person should get daily and how much extra someone should take. Calcium rich foods are: milk, cheese, yogurt, greens, broccoli, sardines, canned salmon with bones, dried beans and peas, calcium-fortified foods such as calcium-fortified orange juice, and tofu.
Vitamin D helps the absorption of calcium. It is found in fortified milk and cereals. Your body can make its own Vitamin D when your skin is exposed to sunshine. Getting Vitamin D from the sun is very helpful but it is recommended to have limited sun exposure with an autoimmune disease. Remember though, when you go out in sun to wear a hat especially if you have lesions.
Weight bearing exercises (walking, jumping, dancing) are helpful in keeping bones healthy.
Another result of taking prednisone for a long time is the increase in cholesterol. There are two basic types of cholesterol that are measured – High Density Lipoprotein (HDL) and Low Density Lipoproteins (LDL). HDL measures “good” cholesterol and LDL measures “bad” cholesterol. Tryglicerides may also be watched as well. It is important to have high HDLs and low LDLs for health. Often cholesterol lowering drugs are called for, but often it is possible to change these factors with diet
It is possible to lower cholesterol naturally. Eating more servings of fruits and vegetables can help provide a greater drop in the cholesterol count because these foods are a good source of soluble fiber. Soluble fiber lowers the LDL or “bad” cholesterol. The specific foods that are particularly high in soluble fiber are apples, citrus fruit, berries, carrots, apricots, prunes, cabbage, sweet potatoes and Brussels sprouts. 1/2 cup is considered a serving size is. All of the beans or legumes also provide soluble fiber. Foods with Omega-3 fatty acids – salmon, sardines, tuna can work wonders in raising HDL levels.
In some recent studies ingredients known as stanol esters and plant sterols that block the absorption of cholesterol from the intestines, have shown to be effective in reducing cholesterol as well. Some foods with sterols are beans, seeds, and cereals – oats and bran especially. Soy products as well have sterols and traces can be found in fruits and vegetables. There are currently several butter substitute products out that contain sterols and research has shown some indication that these products help also in lowering cholesterol.
Lecithin might be helpful in lowering cholesterol as well, Lecithin is a fatlike substance reduced by every the liver and found in varying quantities in body cells and organs. Lecithin helps to emulsify fats and contains the B vitamin choline, from which the body manufactures one of several nerve transmitters. Lecithin metabolizes fat in the liver. In the bloodstream, lecithin prevents fats from accumulating on the walls of arteries. In the intestinal tract, lecithin enhances the absorption of vitamins A, D, and possibly E and K.
Steroids can also slow down the normal repairing of skin cells by one's own body. Vitamin E is needed for normal body metabolism. It helps in the protection and healing of body tissues and skin. Eating foods with Vitamin E can possibly help your skin. Foods that are good sources of Vitamin E are vegetable oils, nuts, and green leafy vegetables. Fortified cereals are also a good source. Keep the body hydrated by drinking a lot of water. Keep the skin moist with lotions. As we age the skin the skin repairs itself more slowly.
One of the leading problems with steroid use is steroid-induced diabetes. The pancreas produces insulin. Insulin helps the body burn sugar for energy. Sugar is fuel for your cells. Insulin takes the sugar from the blood and delivers it into the cells. When blood sugar goes up the cells may be starved for energy. This can eventually cause problems with the kidneys, nerves, heart and eyes. Diabetes is the pancreas' inability to produce insulin. Corticosteriods interferes with the production of insulin. If the pancreas is working normally, it will increase the insulin produced normally when steroids are added in. When the body's pancreas is not strong enough to increase the insulin levels on its own, it will not keep a normal level of blood sugar, and the blood sugar increases. This is steroid-induced diabetes. If this occurs, it is often necessary to take medication that will help the pancreas monitor the blood sugar levels. If the blood sugar levels are borderline with steroids, lowering, dramatically, the intake of carbohydrates can often keep a hold on blood sugar levels.
Ulcers and gastric problems can accompany the use of steroids. The stomach produces a protective mucous layer that helps it defend itself against the acid it produces. Corticosteroids suppress the growth of gastric mucin, cells that produce mucous. This suppression interferes with production of the mucous layer. In addition, corticosteroids inhibit the production of mucous in the cells that remain. Eventually, this leads to a thinning of the protective layer and a greater risk of ulcer. There are many good medicines used today both over-the-counter and with prescription that have virtually no side effects and can help reduce the problems. Some good suggestions to relieve symptoms of ulcers or gastritis – eat smaller meals. Milk may give some initial relief. Add protein to your diet. If possible, avoid cafeinated coffee, large amounts of chocolate, citrus and tomato products. Try not to snack at bedtime as this can cause gastric acid secretions during the night. Ginger tea (even ginger candies) is a wonderful way to reduce stomach discomfort. Some people find Peppermint helps. Others find that Peppermint can give them heartburn.
Basically, what is best for people taking steroids is to eat as healthy as possible. Keeping your weight down is so important. As weight can exacerbate some steroid side effects such as steroids-induced diabetes, high-blood pressure, and high cholesterol, losing weight while there is control of the disease and the steroid doses are down, can make a significant difference. Add extra protein, cut out simple sugars, and add in more fruits and vegetables. There are wonderful recipes in books and online that can make the change in our eating habits more enjoyable. Seek the help of a therapist to deal with the many issues that surround disease and drug side effects.