February 2021 Issue
Nutrition Support in Lyme Disease Treatment — What Dietitians Need to Know Plus Strategies for Counseling Patients
By Jamie Santa Cruz
Vol. 23, No. 2, P. 38
Lyme disease, transmitted through the bites of black-legged ticks, is the most common vector-borne disease in the United States.1
The disease has been called the great imitator, because many Lyme symptoms are nonspecific and it can be difficult to distinguish from other health problems. But for patients who have Lyme disease—and especially for the minority of patients who have prolonged symptoms even after receiving the standard course of antibiotic treatment—it can be a debilitating condition. While nutrition interventions don’t provide a cure for Lyme, they can play an important role in reducing symptoms.
Background on Lyme
The Centers for Disease Control and Prevention (CDC) receives reports of approximately 30,000 cases of Lyme disease from state health departments every year. However, only a fraction of cases are reported, and the CDC estimates the true number of annual cases is closer to 300,000.2
Almost all cases of Lyme in North America are caused by the spirochete Borrelia burgdorferi, although other Borrelia species are present in the United States and can cause either Lyme disease or a Lyme-like illness.3,4 Children between the ages of 5 and 10 are at the highest risk of Lyme, with almost double the risk of adults.5
Lyme disease occurs mainly in regions where ecological conditions support large populations of ticks. The vast majority of reported cases in the United States occur in New England, the Mid-Atlantic states, Wisconsin, and Minnesota,6 but infected ticks appear to be prevalent in certain parts of the West Coast as well, and cases have been found in all 50 states.7 The geographic range of black-legged ticks is increasing, due in part to changes in climate and in land use patterns,8 which has contributed to a steady increase in the incidence of Lyme over the past three decades.
Lyme disease is a multisystemic infection that can affect the skin, joints, heart, and central nervous system. In the disease’s early stages, a common clinical manifestation is a rash (called an erythema migrans) at the site of the tick bite. The rash appears within a few days of the bite up to 30 days, then grows in size over the subsequent days and weeks. Smaller secondary rashes sometimes appear after a few weeks. Other common systemic symptoms of Lyme disease in its earlier stages are a stiff neck, headache, facial nerve palsy, meningitis, fever, fatigue, musculoskeletal pain (that may be migratory in nature), neurocognitive difficulties, and dizziness.1,5
Other symptoms can develop late in the disease course, weeks or months after the initial infection. The most common late symptom in the United States is arthritis (primarily affecting the large joints),9 but neurologic symptoms such as memory deficits, spatial problems, and brain fog are also common.10,11
Diagnosis and Treatment
If a patient has a classic erythema migrans rash and a known exposure to black-legged ticks, diagnosis is comparatively straightforward. However, a large percentage of patients don’t develop a rash,12-14 and the rash in its early stages (before it has spread) can be confused with rashes stemming from other causes.5 The other clinical manifestations of Lyme aren’t specific, except for migratory pain,15 so it’s impossible to make a diagnosis based on those symptoms. This means it can be difficult to diagnose Lyme disease in its early stages.
Confirmation of a Lyme diagnosis typically is done through lab testing for B burgdorferi antibodies, but these tests have limitations. They often can’t detect Lyme in the first few weeks of the disease course, before the body has had time to develop antibodies.9 Even if testing is done at the right stage of disease, antibody tests are better at detecting Lyme antibodies in patients with certain presentations (eg, Lyme arthritis) than others (eg, neurologic symptoms).16,17 Finally, in patients who receive antibiotic treatment early, antibody tests often remain negative even when the characteristic Lyme rash proves the patient was infected.5 Antibody tests also can produce false-positives, in part because they occasionally pick up antibodies from other diseases.18 Accordingly, diagnosis of Lyme disease often is made through a combination of lab testing, an evaluation of symptoms, and consideration of other diseases that might be causing the same symptoms.
Once a patient has been diagnosed with Lyme disease, treatment ordinarily consists of a course of antibiotics. Guidelines from the CDC and the Infectious Disease Society of America recommend a course of one to four weeks.19,20 However, guidelines from the International Lyme and Associated Diseases Society (ILADS) recommend a minimum of 20 days of antibiotics (up to eight weeks in some cases), on the grounds that shorter courses of antibiotics have high failure rates and increase the risk of developing a chronic form of Lyme disease.21-23
Chronic Lyme Disease and Posttreatment Lyme Disease Syndrome
Many patients with Lyme disease recover after a short antibiotic course. However, a subset of Lyme patients continues to experience symptoms months or years later, and some don’t receive a diagnosis until they’ve experienced prolonged symptoms.21,24,25 These patients are said to have chronic Lyme disease (CLD) or posttreatment Lyme disease syndrome (PTLDS).26
CLD is a controversial topic, and clinical practice guidelines from certain North American medical societies reject it as a legitimate diagnosis.18 This is because of concern that “chronic Lyme” often is a misdiagnosis of some other condition. Many patients who are said to have CLD never had an erythema migrans rash or a positive result from antibody testing for B burgdorferi; they were diagnosed with Lyme because no alternative diagnosis was available for their symptoms. Even among chronically ill patients who received a positive result from antibody testing, there’s concern that the result was a false-positive and that the symptoms are due to another cause.18
However, the ILADS treatment guidelines provide peer-reviewed evidence showing that Lyme disease indeed can persist in the body after standard treatment with antibiotics.21 These patients show no objective evidence of an ongoing B burgdorferi infection, but they continue to have symptoms such as fatigue, musculoskeletal pain, cognitive dysfunction, and associated functional impairment.1
It’s unknown why some patients experience chronic Lyme symptoms. Some theorize that patients experience autoimmune reactions or long-term tissue damage as a result of the initial B burgdorferi infection. Others observe that many Lyme patients acquire coinfections at the same time as the initial Lyme infection (such as babesia and bartonella) that may continue to cause illness even after the Lyme is treated.1
There’s also evidence that persistent, hidden infection with B burgdorferi is to blame. According to Christine Green, MD, an integrative physician in private practice in Mountain View, California, who specializes in chronic infectious diseases, antibiotics successfully kill off infection in most Lyme patients, but in some the antibiotics kill only the weaker bacteria. The more resistant bacteria persist and cause ongoing, difficult-to-treat infection. The reason it can be difficult to provide objective evidence of ongoing infection is that the bacteria-causing infection belong to a class of pathogens called stealth pathogens. “They have the ability to hide from the immune system, and to manipulate the immune system so that they can continue to infect,” says Green, who’s on the boards of both Invisible International and LymeDisease.org. Recent evidence from Johns Hopkins University and the University of New Haven suggests that biofilm and persister forms of B burgdorferi may help explain these long-lasting infections.27-29
Regardless of exactly what causes PTLDS, patients with this syndrome typically have numerous confounding health issues (apart from Lyme disease itself) that impede recovery. Specifically, many patients with PTLDS suffer from one or more coinfections, since infected ticks frequently transmit more that one infection at the same time. They also may suffer from systemic inflammation, immune dysfunction or deficiency, severe Jarisch-Herxheimer reactions that occur as a result of taking antibiotics, dysfunction of the autonomic nervous system, and psychological and hormonal imbalances, among other things.1
Nutrition’s Role in Managing PTLDS
How much of a difference can diet and nutrition interventions make in treating prolonged Lyme symptoms? The answer varies from patient to patient, says Lori Enriquez, MPH, RDN, owner of EatFitHealth.com and a specialist in Lyme disease. “It’s hard to say that diet’s going to make the ultimate big change. It really depends on what the person’s diet was and what their issues are.”
According to Enriquez, who’s also a certified educator for the Dare2B Tick Aware prevention program, the variation in symptoms and specific confounding health issues means it’s difficult to make one-size-fits-all nutrition recommendations for Lyme patients. However, there are a few basic principles that apply across the board. The goals of nutrition interventions in Lyme are to do the following:
• Reduce inflammation. Infection with B burgdorferi triggers the production of a variety of inflammatory cytokines. According to Richard B. Horowitz, MD, an internist in private practice in Hyde Park, New York, and a specialist in Lyme disease, this inflammation is a key reason why patients with Lyme disease have prolonged symptoms. To reduce inflammation, Horowitz recommends supplementing with N-acetylcysteine (NAC), alpha-lipoic acid (ALA), and glutathione, all of which help prevent cytokine storms.30-33 “These three nutritional supplements are very useful for blocking the switch inside the nucleus of our cells [that prompts inflammatory responses]. The switch is called the [nuclear factor]-kappa B. When you use these three supplements, it shuts down the inflammatory process,” says Horowitz, who’s also the author of How Can I Get Better? An Action Plan for Treating Resistant Lyme and Chronic Disease.
However, according to Enriquez, some patients are sensitive to these supplements, so recommendations should be tailored to patients’ individual needs.
Patients with Lyme disease also should be encouraged to adopt an anti-inflammatory eating pattern. Both Enriquez and Horowitz recommend a Mediterranean-style diet.34 Similarly, Green recommends a largely plant-based diet rich in greens and antioxidants. All sources interviewed agree that Lyme disease patients should minimize sugar—in part because sugar may cause inflammation, but also because it provides food for bacteria to thrive on and promotes yeast overgrowth in the colon.35
• Support the gut microbiome. Long-term courses of antibiotics can wreak havoc on gut health and cause significant digestive issues. To protect or restore the microbiome, Enriquez, Horowitz, and Green all encourage their Lyme patients to take probiotics. “When you take a probiotic, it doesn’t stay in the gut—it doesn’t colonize,” Green says. “But they will help our own [healthy] bacteria survive and grow better.”
Good species to look for in a probiotic are Lactobacillus and Bifidobacterium, as these have been shown to help improve bowel function, combat inflammation, boost immune function, and prevent Clostridium difficile infection (which can develop after antibiotic treatments).1 In addition to these species, Enriquez encourages considering good yeasts—especially Saccharomyces boulardii. Although it often isn’t included in multiprobiotics, there’s some research suggesting S boulardii could help prevent C difficile infection as well as overgrowth of candida yeasts (which is common in Lyme patients).36-38
Enriquez encourages Lyme disease patients to take probiotics simultaneously with antibiotics (if they’re on a long-term course). There’s no strong evidence on exactly which probiotics patients should take or at what dosage. However, Enriquez suggests a high number of colony-forming units (CFUs), and she recommends always taking the probiotic two hours before or after the antibiotics.
Green, by contrast, doesn’t worry about probiotics having a large number of CFUs; she simply tries to get patients to take probiotic supplements on a frequent basis—at least daily and perhaps even more than once per day. Since probiotics don’t colonize the gut, she says, it’s important to take them continuously.39
• Disrupt biofilms. Biofilms are communities of bacteria that live together on a surface and are protected by a sticky coating that helps them bind together and makes them resistant to antibiotic treatment. There’s some evidence to suggest that B burgdorferi biofilms play a role in prolonged symptoms of Lyme disease.22,23,27
According to Horowitz, some new research suggests that a variety of essential oils and other supplements are useful for combating biofilms. Cinnamon, clove oil, and oregano oil are the most important agents, but stevia extract, monolaurin (a coconut oil extract), and serrapeptase also are effective.40-43 “These have been published in the last several years to be really excellent at disrupting biofilms and helping with the persister forms of Lyme disease,” Horowitz says. In his own practice, Horowitz encourages patients with Lyme disease to use several of these agents simultaneously.
Combating Co-occurring Health Issues
Although the above principles apply to all patients with Lyme disease, most other nutrition advice concerning them should vary depending on the specific confounding health issues that a given patient with Lyme disease is experiencing. “I don’t think you can make a blanket statement,” Enriquez says. “People need to be evaluated individually.”
A sample of the particular issues individual patients with Lyme disease may experience include the following:
• changes in appetite;
• food allergies and sensitivities;
• nutritional deficiencies;
• histamine sensitivity/mast cell activation;
• gastroparesis (paralysis of the gut, which can inhibit food intake and bowel movements); and
• leaky gut.
Food allergies and sensitivities can be triggered by microbiome disruption, either from B burgdorferi infection itself or from the antibiotics used to treat it. In some cases, food allergies develop due to mast cell activation, in which the body’s mast cells begin reacting inappropriately and excessively with an inflammatory immune response to various triggers that previously caused no such response. There are a variety of medications that can help stabilize mast cells, but dietary changes to avoid trigger foods also may be important.
Identifying specific food allergies and sensitivities is important because eating allergens promotes inflammation, which may in turn worsen Lyme symptoms. “The same inflammatory molecules (cytokines) that are produced during Lyme can be produced if you’re eating allergenic foods,” Horowitz explains. Dietitians should watch for allergic reactions that are immediate but also for reactions that are delayed, according to Horowitz. Patients with Lyme disease are sensitive to different foods, but gluten is a common culprit. Based on Horowitz’s own research, approximately 10% of patients with Lyme disease either have a nonceliac gluten sensitivity or celiac disease.1 Any patient with a suspected gluten sensitivity should receive a workup to verify intolerance, he says.
Common nutritional deficiencies in Lyme disease patients include copper, zinc, magnesium, and iodine, according to Horowitz.1 All are essential minerals, so dietitians should check their patients’ levels of each—but not just serum levels. “A lot of these minerals are inside the cells, so you also have to check RBC (red blood cell) levels of magnesium, zinc, and copper,” he explains.
For patients with Lyme disease dealing with either leaky gut or gastroparesis, fiber is an important concern. “Gastroparesis really messes with your biome,” Green says, noting that the condition is usually intermittent. For patients with this condition, “I often give fiber for the same reason as probiotics. It helps the good bacteria and the biofilms in your gut that are good.” Although grains are a good source of fiber, Green recommends focusing on other forms of fiber besides grains, in part because many patients with Lyme disease are sensitive to gluten.1
Bottom Line for RDs
So how can dietitians counsel patients who have Lyme disease? The following steps can help:
• Verify the patient has Lyme disease. To help evaluate the likelihood of Lyme, Horowitz has developed a questionnaire dietitians can administer to patients, a version of which is available at christinegreenmd.com/forms/HMQ-Horowitz-MSIDS-Questionnaire.pdf. According to Horowitz, a score higher than 63 indicates a high probability the patient has Lyme disease. In this case, dietitians should refer patients to a Lyme-literate physician for a medical evaluation, if they haven’t had one.
• Use nutrition to lower inflammation, support the gut microbiome, and disrupt biofilms. In particular, Lyme disease patients can take NAC, ALA, and glutathione supplements if they’re not sensitive to them. They also should eat an anti-inflammatory Mediterranean diet rich in greens and antioxidants. Finally, they should take a probiotic several times per day and make use of the essential oils and extracts (oregano, cinnamon, clove, coconut, stevia) that are known to disrupt biofilms.40-43
• Evaluate specific issues individual patients are experiencing and tailor further nutritional advice based on their personal needs. Check for food allergies or sensitivities, evaluate them for vitamin and mineral deficiencies, and be alert to the possibility of other complications such as mast cell activation or gastroparesis that may require specific nutrition interventions.
Nutrition “is not necessarily the end-all be-all” for Lyme symptoms, Enriquez says. “You still need to have somebody who is what we consider Lyme literate or who is knowledgeable about how to treat Lyme medically.” But while dietary interventions won’t cure Lyme disease by themselves, dietitians have an important role to play. “Nutrition can be a part [of treatment] for sure,” Enriquez says. More information about Lyme disease is available at ilads.org/patient-care/provider-search.
— Jamie Santa Cruz is a health and medical writer based in Parker, Colorado.
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