Malnutrition for Scleroderma

The foods we eat affect our health in many ways, for better or for worse: fruits and vegetables are beneficial foods that provide our bodies with energy and essential nutrients, whereas processed "junk foods" such as cookies, potato chips, and sugary sodas are essentially devoid of nutrients and potentially harmful to our bodies in large amounts. This holds true regardless of age or current health. However, when one is facing a potentially debilitating chronic disease such as scleroderma, in which fatigue, digestive difficulties, and nutrient deficiencies are commonplace, a high-quality, nutritious diet must take center stage to enhance quality of life and successful management of symptoms. While there is no one "diet for scleroderma" per se, as there is much variability in symptoms and severity from person to person, establishing a balanced diet with special emphasis on foods that fight inflammationand provide energy, protein, vitamins, and minerals is paramount.

Systemic sclerosis is a condition in which the immune system over-stimulates the collagen producing cells of the body causing inflammation and an excessive buildup of collagen, leading to hardened skin and fibrosis of internal organs such as the lungs, digestive tract, and blood vessels. While there are no specific foods or nutrients capable of reducing collagen production, the foods you eat can have a positive impact on your disease condition by fighting fatigue, inflammation, and digestive dysfunction. 

Even if you try your best to eat a healthy diet, people who suffer from scleroderma are at increased risk of malnutrition.  Malnutrition in scleroderma is either caused by inadequate intake of nutritious foods or from poor absorption of nutrients from the gastrointestinal (GI) tract.  Someone who eats less due to difficulty chewing, swallowing, and/or preparing his or her own food may suffer from inadequate nutrient intake, thereby causing excessive weight loss and malnutrition.  However, someone suffering from extensive GI involvement may be eating enough food, but is unable to absorb the nutrients properly, resulting in specific vitamin or mineral deficiencies, with or without obvious symptoms.  Therefore, it is important for everyone with scleroderma to have their nutritional status monitored regularly and to eat healthy foods throughout the day from all the different food groups.  Substantial weight loss over a period of 3-6 months can be an indication of inadequate nutrient and calorie intake. Measuring your weight at home at regular intervals can be a simple step towards monitoring your risk of malnutrition.

Symptoms of malnutrition:

• unexplained 10% or more weight loss over a 3 month period
• weakness and muscle wasting
• excessive or new onset fatigue
• increased susceptibility to infection (weakened immunity)
• delayed wound healing 
• brittle nails and excessive hair loss
• excessively dry and flaky skin

The symptoms described above are also related to the underlying scleroderma and may be difficult to distinguish from malnutrition.  New or worsening symptoms (such as worsening fatigue or excessive weight loss) may indicate malnutrition.

Laboratory tests to diagnose malnutrition:

• protein malnutrition:  blood tests to assess total protein, serum albumin, serum  pre-albumin
• specific vitamin/mineral deficiencies: blood tests to assess serum iron, ferritin, total iron binding capacity, zinc, and B-12
• small bowel bacterial overgrowth: blood tests to assess serum folate, carotene, and/or vitamin D levels (see attached article by Dr. Khanna)

If you are under-eating due to difficulties chewing or swallowing, try these suggestions:

• blenderize or juice fresh fruits and vegetables
• make homemade smoothies using fruit, yogurt, 2% milk, Carnation Instant Breakfast and/or whey protein powder
• include soft, moist protein sources at meals and snacks such as cottage cheese, scrambled eggs, yogurt, fish, chicken with gravy, ground meats, macaroni and cheese, and lasagna.

If you have lost an excessive amount of weight, consider the following to help restore weight and nutritional status:

• have your physician rule out small bowel bacterial overgrowth and gastroparesis.
• liberally add sources of healthy fats to your diet by way of olive, canola, and peanut oils; nuts, seeds and nut butters; avocado; fatty fish; and oil-based salad dressings
• make homemade smoothies using fruit, yogurt, 2% milk, 1-2 Tbsp. peanut butter, 1-3 tsp. canola oil, Carnation Instant Breakfast and/or whey protein powder
• consider including a high-protein liquid nutrition supplement (such as Ensure Plus or Boost Plus) between meals 1-3 times per day;  if not tolerated, try Boost Breeze, a high protein juice-based alternative
• eat every 2 hours to maximize calorie and nutrient intake

General Diet Recommendations:

• Eat small, frequent meals every 3-4 hours.  If you have been experiencing excessive weight loss or can only eat small amounts at one time, consider eating every two hours to maximize nutrient intake. 

• Choose fresh, whole, minimally processed foods, without preservatives, artificial ingredients, or hydrogenated oils.  If there are “chemical” sounding names in the ingredient list, avoid it.  In general, the shorter the ingredient list, the better.

• Add antioxidant rich, anti-inflammatory herbs and spices liberally to foods such as basil, rosemary, oregano, cinnamon, ginger, paprika, cayenne, turmeric, and curry powder.

• Cut down on added sugars. (Natural sugar found in fruit, milk, and yogurt is not a concern unless it causes GI distress.)  Check ingredient lists for stealthy terms indicating added sugar such as sucrose, evaporated cane juice, fructose, brown rice syrup, honey, agave nectar, molasses, corn syrup, and maple syrup.

• Consider taking an over the counter multivitamin/mineral supplement containing 15 mg zinc, 10-18 mg iron, vitamins A, D, E, and K, folate, and B-12.  If specific nutrient deficiencies have been identified, extra supplementation may be required.  Taking a probiotic supplement such as Align or Culturelle may help restore intestinal function and help with symptoms of bloating and distention.

• Drink fresh, filtered water that has never been exposed to plastic.  Use a water filtration system at home and drink only from glass or stainless steel containers.  Aim to drink half your body weight in water each day.  (i.e.  75 oz. for a 150 lb. person)

Food Group	Serving size	Choose	Avoid	Suggestions
Fruit 2-3 servings per day	one small whole fruit 1 cup pieces (melon, grapes, berries) 1/4 dried (raisins, cherries) 1/2 cup canned	All varieties in deep colors of the rainbow:  green, red, orange, yellow, purple, & blue.	Those that cause excessive gas, bloating, & GI discomfort.  See low FODMAP diet for details.	Choose organic as often as possible. Choose fresh and frozen over canned varieties.
Vegetables 5-7 servings per day	1 cup raw, chopped 1 cup leafy 1/2 cup cooked	All varieties in deep colors of the rainbow:  green, red, orange, yellow, purple, & blue.	Those that cause excessive gas, bloating, & GI discomfort.  See low FODMAP diet for details.	Choose organic as often as possible. Choose fresh and frozen over canned varieties.
Proteins:  meat, cheese, eggs, nuts, beans aim for : 2-3 oz per meal; 1 oz. per snack	2-3 oz. meat (size of deck of cards) 1 oz. protein equivalents: 1 egg; 1-inch cube cheese; 1 medium slice cheese; 1/4 cup tuna or cottage cheese; 2 Tbsp. nut butter; 1/4 cup nuts; 1/2 cup dried beans	lean beef lean pork skinless chicken turkey fish/tuna organic eggs low-fat cheese nuts/seeds nut butters dried beans (as tolerated)	Highly processed meats such as bacon, sausage, pepperoni, salami, hot dogs, bologna, corned beef, & pastrami. Breaded and deep-fried fish, chicken, pork and beef.	Choose organic or grass fed meat and cheese as often as possible. Remove extra fat and skin from meats before cooking. For healthy omega-3 oils, eat 8-12 oz. of fatty fish, such as salmon, every week.
Milk/Dairy 2-3 servings per day	1 cup milk 6-8 oz. yogurt	Low-fat or fat free varieties. Try Greek-style yogurt for extra protein.	Avoiding lactose-containing dairy products may help resolve problematic GI symptoms.  See low FODMAP diet for details.	Choose organic as often as possible.
Whole Grains 3-6 servings per day	1 slice bread 1/2 cup pasta or rice 3/4 cup cereal 1/2 cup cooked cereal 4-6 crackers	100% whole grains, such as minimally processed whole wheat bread and cereals, barley, quinoa, oats.	Avoiding all foods containing wheat may improve GI symptoms.  See low FODMAP diet for details.	Look for labels that read "100% whole grain".    Choose foods with 3 grams of fiber or more per serving.  Limit white, refined wheat products as much as possible.
Fats/Oils 1-2 servings per day	1 Tbsp oil 1/4 cup nuts 2 Tbsp. seeds 2 Tbsp. nut butter 1/8 avocado	Extra virgin olive, peanut, and canola (rapeseed) oils most often. all nuts, especially almonds, walnuts, flaxseeds, pine nuts. avocado natural peanut butter	Avoid trans fats from hydrogenated and partially hydrogenated oils.  Minimize use of safflower, sunflower, grapeseed, corn, and soybean oils.	Limit solid fats from butter, shortening, and margarine. For healthy omega-3 oils, eat 8-12 oz. of fatty fish, such as salmon or whitefish, every week.

Low FODMAP food guide:

To resolve problematic gastrointestinal symptoms such as severe gas, bloating, discomfort, diarrhea, and/or constipation, consider removing foods containing wheat or dairy (lactose) from your diet, one food item at a time, as such foods are often difficult to digest.  If removing wheat and/or dairy products does not provide relief, the adoption of a low FODMAP diet may prove beneficial. 

FODMAP is an abbreviation for:
Fermentable
Oligosaccharides (fructans and galactans)
Disaccharides (lactose)
Monosaccharides (excess fructose in a food)
And
Polyols (sugar alcohols like sorbitol, maltitol, mannitol, xylitol and isomalt)

FODMAPs are sugars and other carbohydrates found in a variety of foods that tend to be poorly digested and absorbed by the gut. These components are easily fermented by bacteria in the intestine, resulting in abdominal pain, gas, bloating, diarrhea and/or constipation.  When foods rich in FODMAPs are removed from the diet, aggravating gastrointestinal symptoms will often resolve.

FODMAP Category	Foods to avoid	Foods to choose
Oligosaccharides: Fructans & Galactans Fructo-oligosaccharides  (FOS) Galacto-oligosaccharides (GOS)	all wheat & rye containing grains breaded meats brown rice bran cereals inulin  (check ingredient list) balsamic, red wine, & cider vinegar soy legumes (black, kidney, pinto beans, garbanzo, etc.) lentils asparagus, cabbage, broccoli, artichokes, leeks, shallots, squash, green beans, onion, garlic	corn tortillas, grits, oatmeal, unsweetened corn or rice cereals, white rice, barley, rice noodles products labeled "gluten-free" are usually well-tolerated, such as GF bread and pasta celery, spinach, potatoes (white)
Disaccharides:  Lactose	milk and milk products such as yogurt, cheese, pudding, ice cream, custard	lactose-free milk & milk products unsweetened almond milk unsweetened rice milk
Monosaccharides:  containing excess Fructose	apple, pear, watermelon, honeydew, papaya, mango, starfruit, guava, some grape varieties dates, figs, raisins, currants high fructose corn syrup corn syrup solids (check ingredients) honey agave nectar fruit juices contain apple or pear	blueberry, blackberry, boysenberry, cranberry, raspberry, strawberry, loganberry kumquat, grapefruit, lemon, lime, mandarin, orange, tangelo ripe banana, jackfruit, kiwi fruit, passion fruit, pineapple, rhubarb
Polyols	apricot, nectarine, plum, peach pear, apple, cherries, prunes avocado, mushrooms "diet" or "sugar free" labeled foods containing added sugar alcohols (listed above)	None

A one-on-one consultation with a dietitian is recommended to ensure that this restrictive low FODMAP diet will adequately meet your nutritional needs.  To find a dietitian in your area, visit www.eatright.org.

Managing specific scleroderma-related issues:

REFLUX/HEARTBURN:  eat small frequent meals to avoid overfilling your stomach; avoid eating within 2-3 hours of bedtime; avoid foods that may aggravate symptoms such as citrus fruits, tomato products, greasy fried foods, coffee, garlic, onions, peppermint, gas-producing foods (such as raw peppers, beans, broccoli, raw onions), spicy foods, carbonated beverages, and alcohol.  If you carry extra weight around your midsection, weight loss may also improve symptoms.  Use a sleep wedge or elevate head of the bed to elevate your head and torso to prevent regurgitation of stomach contents into airways.

DECREASED GI MOTILITY/CONSTIPATION: exercise, such as walking, helps move food through the digestive tract; eat a high fiber diet with 100% whole grains, fruits and vegetables; take a daily probiotic supplement (such as Align or Culturelle) and/or eat yogurt with active cultures regularly; increase fluid intake.

INFLAMMATION- increase antioxidant intake by choosing deeply colored fruits and vegetables (especially dark green, deep yellow, orange, red, purple, and blue); eat fatty fish, ground flaxseeds, and walnuts for omega-3 fatty acids; eat vitamin E-rich foods such as nuts, seeds, and extra-virgin olive oil; consider taking a 1000 IU Vitamin D3 (cholecalciferol) tablet with your fattiest meal (to allow for better absorption).

FATIGUE- eat small, frequent meals to provide continuous energy and keep blood sugar from dipping low; increase fluid intake; participate in 30-60 minutes of moderate daily exercise such as walking, bike riding, pool exercise, pilates, yoga, or tai chi.  Sleep for 7-8 hours each night.  If iron levels are low, which is typical of someone with chronic disease, discuss additional iron supplementation with your doctor.  If you currently take an iron pill, swallow it down with a juice containing vitamin C to allow for better absorption.

POOR CIRCULATION/RAYNAUD'S- exercise will increase circulation to areas suffering from limited blood flow; if you suffer from finger ulcers, eat animal sources of protein with zinc and iron (such as beef and pork) to accelerate wound healing.

TIGHT, THICKENED SKIN- eat foods rich in vitamin E such as nuts, seeds, wheat germ, and canola, olive, and peanut oils; consider taking 5 mg (5000 mcg) biotin supplement, which may help skin and nails.