March 2017 Issue
Clinical Nutrition: Sjögren's Syndrome's Dietary Impact
By Judith C. Thalheimer, RD, LDN
Vol. 19, No. 3, P. 12
Dietitians have an important role to play in the diagnosis and treatment of this prevalent but little-understood autoimmune disease.
The systemic autoimmune disease known as Sjögren's (SHOW-grins) syndrome has a dramatic impact on dietary intake. It's important that dietitians not only recognize symptoms of this frequently misdiagnosed condition in their clients and patients but also understand nutrition and behavioral interventions that can help ease the impact of this chronic disease on quality of life and nutrient intake.
Sjögren's is one of the most prevalent autoimmune diseases, with upwards of 4 million diagnosed cases in the United States. It affects nearly every racial and ethnic group, and nine out of 10 patients are women.1 "Sjögren's syndrome is an autoimmune disease that attacks the exocrine glands, like the lacrimal glands of the eyes and the salivary glands," says Frederick B. Vivino, MD, MS, FACR, director of the Penn Sjögren's Syndrome Center, chief of the division of rheumatology at Penn Presbyterian Medical Center, and a professor of clinical medicine at the Perelman School of Medicine of the University of Pennsylvania. "This causes dry eyes and mouth, and many Sjögren's patients also have systemic inflammation that causes extreme fatigue and musculoskeletal pain." This disease affects the entire body and can cause dysfunction of the kidneys, blood vessels, lungs, liver, pancreas, and central nervous system.1 Patients also are at increased risk of developing lymphomas.1 Sjögren's often is accompanied by other autoimmune connective tissue diseases such as rheumatoid arthritis, lupus, or scleroderma.1
There's little scientific research on dietary interventions for the treatment of Sjögren's syndrome. Nonetheless, many of the symptoms that directly and dramatically impact food intake and quality of life for Sjögren's patients, such as dry mouth, compromised dentition, and reflux, can be significantly improved through dietary modification.
Sjögren's syndrome can affect the entire gastrointestinal (GI) system, from the mouth, esophagus, and bowel to the liver and pancreas.2 While there's no recommended diet known to improve Sjögren's syndrome, there are established dietary measures that can help ease symptoms or improve nutritional intake. "This condition has a significant impact on food intake," Vivino says. "About 10% of my patients present with unintended weight loss."
"One of the primary effects of Sjögren's syndrome is its attack on the salivary glands," says Steven I. Present, DMD, a clinical associate professor at Kornberg School of Dentistry of Temple University, and a fellow of the international team for implantology. The resulting dry mouth (xerostomia) puts patients at high risk of conditions that make eating difficult. "These patients suffer from rampant dental caries directly related to the changes in salivary output and quality," Present says. This can lead to pain and tooth loss. Reducing intake of sugary foods and beverages and brushing teeth soon after eating are recommended.3 "Reduced salivary function also leads to a microbial shift in the oral cavity, which can result in painful bacterial and fungal infections," Present says. Patients are often trying to eat with dysgeusia (altered taste), a sore tongue, burning mouth, and mouth sores or ulcers, according to Vivino. Swallowing can be difficult as well. "Without adequate saliva acting as a lubricant, it's hard to swallow food," Present says.
To address all of these issues, it's important to keep foods moist and soft.1 Using gravies, soaking, or overcooking foods to make them softer can help.1 Foods that may be difficult to chew or swallow, such as meats and hard fruits, should be cut into very small pieces.3 Food that's too hot or too cold can be irritating, as can spices like pepper and acidic foods like citrus, vinegar, and tomatoes.1,3 "There's no one presentation for this disease," says Steven Taylor, CEO of the Sjögren's Syndrome Foundation. "Some can eat oranges, some can't; some can never eat salad dressing, some can tolerate creamy dressings." Drinking water can help wet the mouth, but it shouldn't be overdone. "Paradoxically, drinking more water doesn't help the disease," Taylor says. "It actually dilutes the saliva. Patients should sip water when they need it, but not drink extra water all day long." Artificially sweetened sour hard candy can help stimulate saliva production, and medications are available to improve salivary output.3
Without adequate saliva to neutralize stomach acid, Sjögren's patients often will suffer from reflux. Nutrition and lifestyle recommendations for any patient with gastroesophageal reflux disease can be used for these patients as well. While trigger foods vary, fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine are common heartburn triggers. Patients with reflux should eat smaller meals and should wait at least three hours after eating before lying down. Maintaining a healthy weight, avoiding tight clothing, not smoking, and elevating the head of the bed 6 to 9 inches also are recommended for reducing reflux.4
Other GI Conditions
The effect of Sjögren's on diet and intake extends beyond the mouth to the entire digestive system. "Sjögren's patients are prone to small intestinal bacterial overgrowth, which causes malabsorption and symptoms like bloating and diarrhea," Vivino says. "They have a higher likelihood of gastroparesis, and there seems to be an association with an increased incidence of celiac disease." According to the Sjögren's Syndrome Foundation, celiac disease affects 7% to 10% of Sjögren's patients. Up to 49% of patients have abnormal liver tests, and pancreatitis and pancreatic insufficiency, although rare, are possible.2
Celiac disease or nonceliac gluten sensitivity should be treated with a gluten-free diet, and patients with liver, pancreatic, motility, or other GI problems should be counseled on appropriate MNT for these conditions, factoring in which foods will be difficult to eat with a dry mouth or poor dentition. Watch for deficiencies of vitamins C, B12 and B6, folate, and iron. If these can't be managed with a balanced diet, vitamin supplementation may be necessary.3
Lauri Lang, RDN, LDN, a private practice dietitian with a special interest in autoimmune conditions, has worked with several Sjögren's patients and has had success with dietary and lifestyle changes as yet untested by scientific studies in this patient population. Lang recommends her clients follow an anti-inflammatory diet (see sidebar for a link to more information) with an emphasis on a healthful dietary pattern that stresses colorful whole fruits and vegetables, healthful fats like fish oils, and fiber. She particularly stresses eating a gluten-free diet, and has observed improvement in her clients who do so.
"We see a significant percentage of patients trying to live a gluten-free or grain-free lifestyle," Taylor says. "Many seem to feel better, but there's no data on why."
The Dietitian's Role
"People know that things like fruits, leafy greens, and red wine are good for their health. But when you can't drink wine and need to stay away from acidic fruits because you have dry mouth, and tooth decay and swallowing problems make many foods, including lettuces, difficult to eat, following standard nutrition advice can be difficult," Taylor says. "These patients can benefit from individual guidance to help them find a healthful way of eating that works with their limitations." Dietitians can provide individualized advice that takes into account all of the issues a patient is facing, and help them integrate these changes into their lives.
"When someone is dealing with a chronic illness, they feel out of control and powerless," Lang says. "Taking control of their diet makes them feel empowered."
In addition to dietary interventions, nutrition professionals also have a role to play in diagnosis. "A lot of patients don't realize they have dry mouth." Taylor says. "They just drink all day. And primary physicians don't typically ask about tooth decay at a check-up. An RD can be a first line of defense for someone who has these symptoms."
Vivino agrees: "If a dietitian sees a patient with symptoms like reflux, dyspepsia, dental caries, or weight loss, asking questions about dry eyes, mouth, or vaginal tissues in an initial evaluation could help identify undiagnosed cases of Sjögren's," Vivino says.
"If you think someone has Sjögren's symptoms, refer to a rheumatologist or their primary physician, and point them to the Sjögren's Foundation website to learn more about the disease," Taylor says. "RDs also can help by partnering with rheumatologists. There's a major opportunity to have a career helping patients with chronic rheumatologic illnesses. I hope dietitians will reach out to their local rheumatologists and let them know they're available for referrals."
— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer, a community educator, and the principal of JTRD Nutrition Education Services, LLC.
1. About Sjögren's. Sjögren's Syndrome Foundation website. https://www.sjogrens.org/home/about-sjogrens
2. Ebert EC. Gastrointestinal and hepatic manifestations of Sjogren syndrome. J Clin Gastroenterol. 2012;46(1):25-30.
3. Mahan KL, Escott-Stump S, Raymond JL. Krause's Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012.
4. Mayo Clinic staff. GERD: lifestyle and home remedies. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/gerd/basics/lifestyle-home-remedies/con-20025201. Updated July 31, 2014.
• Sjögren's Syndrome Foundation, www.sjogrens.org
• National Institute of Dental and Craniofacial Research, www.nidcr.nih.gov/OralHealth/Topics/DryMouth/DryMouth.htm
• Cleveland Clinic, http://my.clevelandclinic.org/health/articles/dry-mouth-treatments
• Patient Education Sheet, www.sjogrens.org/files/brochures/anti-inflammatory_diet.pdf