Healthy lifestyle habits for patients with systemic lupus erythematosus: A systemic review

The effects of lifestyle interventions on disease activity and quality of life in patients with systemic lupus erythematosus: A systematic review

INTRODUCTION

Systemic Lupus Erythematosus (SLE) is an autoimmune disease affecting multiple organs, characterized by flares and remission. Treatment aims to reduce flare severity and prevent long-term damage, but remission is often elusive, and patients may still experience flares and a reduced quality of life (QoL). This had led to a growing interest in non-pharmacological therapies to improve patient wellbeing.

OBJECTIVE

We aimed to assess and summarize the efficacy of lifestyle interventions in SLE patients on disease activity and QoL.

METHODS

A systematic search on lifestyle interventions, SLE, disease activity, and QoL was conducted in PubMed/Medline, Embase and Clinicaltrials.gov in August 2024. Included studies were randomized controlled trials on lifestyle interventions in adult SLE patients. Each trial was appraised using Scottish Intercollegiate Guidelines Network (SIGN) criteria, with participant numbers, study duration, intervention type and outcome measures detailed in separate tables.

RESULTS

A total of 3564 articles were screened, resulting in the inclusion of 25 randomized controlled trials with 1521 patients. Study quality varied from high (11 studies) to low (6 studies) with considerable intervention heterogeneity. The interventions fell into five categories: physical activity, psychotherapy, lifestyle coaching, supplements and dietary interventions. Physical activity (2 studies, 116 patients), psychotherapy (5 studies, 507 patients) and coaching (1 study with 30 patients) had no significant effect on disease activity, while fish oil supplementation showed a slight benefit in two studies with a total of 102 patients. Quality of life generally improved with physical activity (4 studies with in total 253 patients) and psychotherapy (9 studies with in total 623 patients), with significant mental health benefits, but coaching (3 studies with in total 186 patients) showed no effect.

CONCLUSION

Various lifestyle interventions influence quality of life in SLE patients. Consistent with recent guidelines, both exercise and psychotherapy may positively impact the health-related quality of life in these patients. However, some studies were biased due to self-reported outcomes and the Hawthorne effect, where participants' behavior changed from receiving extra attention. Further research with larger patient cohorts is necessary to reduce the influence of heterogeneity across different studies and to better understand the potential of these promising therapies.

EULAR recommendations for the non-pharmacological management of systemic lupus erythematosus and systemic sclerosis

OBJECTIVE

To develop evidence-based recommendations for the non-pharmacological management of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc).

METHODS

A task force comprising 7 rheumatologists, 15 other healthcare professionals and 3 patients was established. Following a systematic literature review performed to inform the recommendations, statements were formulated, discussed during online meetings and graded based on risk of bias assessment, level of evidence (LoE) and strength of recommendation (SoR; scale A-D, A comprising consistent LoE 1 studies, D comprising LoE 4 or inconsistent studies), following the European Alliance of Associations for Rheumatology standard operating procedure. Level of agreement (LoA; scale 0-10, 0 denoting complete disagreement, 10 denoting complete agreement) was determined for each statement through online voting.

RESULTS

Four overarching principles and 12 recommendations were developed. These concerned common and disease-specific aspects of non-pharmacological management. SoR ranged from A to D. The mean LoA with the overarching principles and recommendations ranged from 8.4 to 9.7. Briefly, non-pharmacological management of SLE and SSc should be tailored, person-centred and participatory. It is not intended to preclude but rather complement pharmacotherapy. Patients should be offered education and support for physical exercise, smoking cessation and avoidance of cold exposure. Photoprotection and psychosocial interventions are important for SLE patients, while mouth and hand exercises are important in SSc.

CONCLUSIONS

The recommendations will guide healthcare professionals and patients towards a holistic and personalised management of SLE and SSc. Research and educational agendas were developed to address needs towards a higher evidence level, enhancement of clinician-patient communication and improved outcomes.

Efficacy of lifestyle interventions in the management of systemic lupus erythematosus: a systematic review of the literature

We performed a systematic review to explore existing evidence regarding the efficacy of lifestyle interventions for the management of systemic lupus erythematosus (SLE). The search was conducted on the 22nd of June 2021 for publications between 1st of January 2000 and the date of search. Additional articles within the aforementioned timeframe and until December 2023 were added by hand searching. Databases utilized were Medline, Embase, Web of Science, and Cinahl. Lifestyle interventions were defined as any intervention encompassing one or more of the following: physical exercise, diet and nutrition, mental health, harmful exposures, sleep, and social relations. The Joanna Briggs Institute critical appraisal tools were used for risk of bias assessment. The search yielded 11,274 unique records, we assessed the full text of 199 records, and finally included 102 studies. Overall, the quality of the evidence is limited, and there were multiple sources of heterogeneity. The two domains most extensively researched were mental health (40 records) and physical exercise (39 records). Psychological interventions had a positive effect on depressive symptoms, anxiety, and health-related quality of life (HRQoL), whereas physical exercise improved fatigue, depressive symptoms, aerobic capacity, and physical functioning. Studies on diet and nutrition (15 records) support that low fat intake and Mediterranean diet may be beneficial for reducing cardiovascular risk, but large interventional studies are lacking. Studies on harmful exposures (7 records) support photoprotection and use of sunscreen. While studies imply benefits regarding disease burden and drug efficacy in non-smokers and regarding HRQoL in normal-weight patients, more survey is needed on tobacco smoking and alcohol consumption, as well as weight control strategies. Studies on social relations (1 record) and sleep (no records) were sparse or non-existent. In conclusion, psychosocial interventions are viable for managing depressive symptoms, and exercise appears essential for reducing fatigue and improving aerobic capacity and physical function. Photoprotection should be recommended to all patients. Lifestyle interventions should be considered a complement, not a substitute, to pharmacotherapy.

Effects of a lifestyle intervention on cardiovascular risk factors in systemic lupus erythematosus patients: The study "Living well with lupus"

OBJECTIVE

The aim of the present study was to investigate the effects of a lifestyle intervention on cardiometabolic risk factors in patients with systemic lupus erythematosus with a high cardiovascular risk profile.

METHODS

This trial was conducted in Sao Paulo, Brazil between August 2020 and March 2023. The patients were randomly assigned to lifestyle intervention or control. The intervention was a 6-month multifaced program focused on behavioral changes through personalized recommendations for increasing physical activity (structured and non-structured) and improving eating aspects. Cardiometabolic risk score (primary outcome), anthropometry and visceral fat, aerobic capacity, blood pressure, inflammatory and oxidative stress markers, and blood flow and endothelial function were assessed before and after the intervention.

RESULTS

A total of 80 patients were randomized. Twelve and 6 patients dropped out due to personal reasons in the intervention and control groups, respectively. Average adherence rate for the intervention was 56.9%. Intention-to-treat analysis showed no significant difference between groups in the cardiometabolic risk score (intervention group - Pre: 1.7 ± 3.6; Post: -1.6 ± 4.0; control group - Pre: -1.9 ± 3.6; Post: -2.0 ± 3.8; estimated mean difference between groups at post: -0.4; 95% confidence intervals: -2.7; 1.9; p = 0.96). This finding was confirmed by exploratory, per-protocol analysis. No significant differences were observed between adherents vs. non-adherent participants. Secondary outcomes did not change between groups.

CONCLUSION

This 6-month, individualized, lifestyle intervention did not improve cardiovascular risk factors in SLE patients with a high cardiovascular risk profile.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04431167).

A randomized controlled trial of an intervention promoting physical activity and healthy eating recommendations in systemic lupus erythematosus: the protocol study "Living Well with Lupus"

There is a paucity of studies assessing multidisciplinary interventions focused on tackling physical inactivity/sedentary behavior and poor dietary habits in SLE. The Living well with Lupus (LWWL) is a randomized controlled trial to investigate whether a six-month lifestyle change intervention will improve cardiometabolic risk factors (primary outcome) among systemic lupus erythematosus (SLE) patients with low disease activity (SLEDAI score ≤ 4) and with high cardiovascular risk. As secondary goals, we will evaluate: (1) the intervention's safety, efficacy, and feasibility in promoting lifestyle changes, and (2) the effects of the intervention on secondary outcomes (i.e., clinical parameters, functional capacity, fatigue, psychological aspects, sleep quality and health-related quality of life). Patients will be randomly allocated to either a control (i.e., standard care) or a lifestyle intervention group using a simple randomization (1:1 ratio, blocks of 20). Mixed Model analyses will be conducted for comparing groups following an intention-to-treat approach. A per protocol analysis will also be conducted. This study has the potential to generate new, clinically relevant data able to refine the multidisciplinary management of SLE patients. Protocol version number: NCT04431167 (first version).

Perceived Stress and Prediction of Worse Disease Activity and Symptoms in a Multiracial, Multiethnic Systemic Lupus Erythematosus Cohort

OBJECTIVE

Studies have suggested a potential link between traumatic experiences, psychological stress, and autoimmunity, but the impact of stress on disease activity and symptom severity in systemic lupus erythematosus (SLE) remains unclear. The present study was undertaken to examine whether increases in perceived stress independently associate with worse SLE disease outcomes over 3 years of follow-up.

METHODS

Participants were drawn from the California Lupus Epidemiology Study (CLUES). Stress was measured annually using the 4-item Perceived Stress Scale (PSS). Participants with increases of ≥0.5 SD in PSS score were defined as having an increase in stress. Four outcomes were measured at the year 3 follow-up visit: physician-assessed disease activity (Systemic Lupus Erythematosus Disease Activity Index); patient-reported disease activity (Systemic Lupus Activity Questionnaire); pain (Patient-Reported Outcomes Measurement Information System [PROMIS] pain interference scale); and fatigue (PROMIS fatigue scale). Multivariable linear regression evaluated longitudinal associations of increase in stress with all 4 outcomes while controlling for potential confounders.

RESULTS

The sample (n = 260) was 91% female, 36% Asian, 30% White, 22% Hispanic, and 11% African American; the mean ± SD age was 46 ± 14 years. In adjusted longitudinal analyses, increase in stress was independently associated with greater physician-assessed disease activity (P = 0.015), greater self-reported disease activity (P < 0.001), more pain (P = 0.019), and more fatigue (P < 0.001).

CONCLUSION

In a racially diverse sample of individuals with SLE, those who experienced an increase in stress had significantly worse disease activity and greater symptom burden at follow-up compared to those with stress levels that remained stable or declined. Findings underscore the need for interventions to bolster stress resilience and support effective coping strategies among individuals living with lupus.

A Review of the Potential Benefits of Herbal Medicines, Small Molecules of Natural Sources, and Supplements for Health Promotion in Lupus Conditions

The Latin word lupus, meaning wolf, was in the medical literature prior to the 1200s to describe skin lesions that devour flesh, and the resources available to physicians to help people were limited. The present text reviews the ethnobotanical and pharmacological aspects of medicinal plants and purified molecules from natural sources with efficacy against lupus conditions. Among these molecules are artemisinin and its derivatives, antroquinonol, baicalin, curcumin, emodin, mangiferin, salvianolic acid A, triptolide, the total glycosides of paeony (TGP), and other supplements such as fatty acids and vitamins. In addition, medicinal plants, herbal remedies, mushrooms, and fungi that have been investigated for their effects on different lupus conditions through clinical trials, in vivo, in vitro, or in silico studies are reviewed. A special emphasis was placed on clinical trials, active phytochemicals, and their mechanisms of action. This review can be helpful for researchers in designing new goal-oriented studies. It can also help practitioners gain insight into recent updates on supplements that might help patients suffering from lupus conditions.

Differential impact of environmental factors on systemic and localized autoimmunity

The influence of environmental factors on the development of autoimmune disease is being broadly investigated to better understand the multifactorial nature of autoimmune pathogenesis and to identify potential areas of intervention. Areas of particular interest include the influence of lifestyle, nutrition, and vitamin deficiencies on autoimmunity and chronic inflammation. In this review, we discuss how particular lifestyles and dietary patterns may contribute to or modulate autoimmunity. We explored this concept through a spectrum of several autoimmune diseases including Multiple Sclerosis (MS), Systemic Lupus Erythematosus (SLE) and Alopecia Areata (AA) affecting the central nervous system, whole body, and the hair follicles, respectively. A clear commonality between the autoimmune conditions of interest here is low Vitamin D, a well-researched hormone in the context of autoimmunity with pleiotropic immunomodulatory and anti-inflammatory effects. While low levels are often correlated with disease activity and progression in MS and AA, the relationship is less clear in SLE. Despite strong associations with autoimmunity, we lack conclusive evidence which elucidates its role in contributing to pathogenesis or simply as a result of chronic inflammation. In a similar vein, other vitamins impacting the development and course of these diseases are explored in this review, and overall diet and lifestyle. Recent work exploring the effects of dietary interventions on MS showed that a balanced diet was linked to improvement in clinical parameters, comorbid conditions, and overall quality of life for patients. In patients with MS, SLE and AA, certain diets and supplements are linked to lower incidence and improved symptoms. Conversely, obesity during adolescence was linked with higher incidence of MS while in SLE it was associated with organ damage. Autoimmunity is thought to emerge from the complex interplay between environmental factors and genetic background. Although the scope of this review focuses on environmental factors, it is imperative to elaborate the interaction between genetic susceptibility and environment due to the multifactorial origin of these disease. Here, we offer a comprehensive review about the influence of recent environmental and lifestyle factors on these autoimmune diseases and potential translation into therapeutic interventions.

Inflammation and endothelial function-related gene polymorphisms are associated with carotid atherosclerosis-A study of community population in Southwest China

OBJECTIVES

To investigate the relationships between 18 single nucleotide polymorphisms with carotid atherosclerosis and whether interactions among these genes were associated with an increased risk of carotid atherosclerosis.

METHODS

Face-to-face surveys were conducted with individuals aged 40 or older in eight communities. A total of 2377 individuals were included in the study. Ultrasound was used to detect carotid atherosclerosis in the included population. 18 loci of 10 genes associated with inflammation and endothelial function were detected. Gene-gene interactions were analyzed using generalized multifactor dimensionality reduction (GMDR).

RESULTS

Among the 2377 subjects, 445 (18.7%) subjects had increased intima-media thickness in the common carotid artery (CCA-IMT), and 398 (16.7%) subjects were detected with vulnerable plaque. In addition, NOS2A rs2297518 polymorphism was associated with increased CCA-IMT, IL1A rs1609682, and HABP2 rs7923349 polymorphisms were associated with vulnerable plaque. Besides, GMDR analysis showed significant gene-gene interactions among TNFSF4 rs1234313, IL1A rs1609682, TLR4 rs1927911, ITGA2 rs1991013, NOS2A rs2297518, IL6R rs4845625, ITGA2 rs4865756, HABP2 rs7923349, NOS2A rs8081248, HABP2 rs932650.

CONCLUSION

The prevalences of increased CCA-IMT and vulnerable plaque were high in Southwestern China's high-risk stroke population. Furthermore, inflammation and endothelial function-related gene polymorphisms were associated with carotid atherosclerosis.

2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases

OBJECTIVES

A European League Against Rheumatism taskforce was convened to review the literature and develop recommendations on lifestyle behaviours for rheumatic and musculoskeletal diseases (RMDs).

METHODS

Six lifestyle exposures (exercise, diet, weight, alcohol, smoking, work participation) and seven RMDs (osteoarthritis, rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, systemic sclerosis, gout) were considered. The taskforce included health professionals in rheumatology, geriatricians, epidemiologists, public health experts, people with RMDs and exposure domain experts. Systematic reviews were conducted to gather available evidence, from which recommendations were developed.

RESULTS

Five overarching principles and 18 specific recommendations were defined based on available evidence. The overarching principles define the importance of a healthy lifestyle, how lifestyle modifications should be implemented, and their role in relation to medical treatments. Exercise recommendations highlight the safety and benefits of exercise on pain and disability, particularly among people with osteoarthritis and axial spondyloarthritis. The diet recommendations emphasise the importance of a healthy, balanced diet for people with RMDs. People with RMDs and health professionals should work together to achieve and maintain a healthy weight. Small amounts of alcohol are unlikely to negatively affect the outcomes of people with RMDs, although people with rheumatoid arthritis and gout may be at risk of flares after moderate alcohol consumption. Smokers should be supported to quit. Work participation may have benefits on RMD outcomes and should be discussed in consultations.

CONCLUSIONS

These recommendations cover a range of lifestyle behaviours and can guide shared decision making between people with RMDs and health professionals when developing and monitoring treatment plans.

The ABC-associated Immunosenescence and Lifestyle Interventions in Autoimmune Disease

Aging-associated immune changes, termed immunosenescence, occur with impaired robust immune responses. This immune response is closely related to a greater risk of development of autoimmune disease (AID), which results in increased levels of autoantibodies and increased morbidity and mortality. In addition, lifestyle-related risk factors play a pivotal role in AID, which may be probable via senescence-related immune cell subsets. Age-associated B cell (ABC) subsets have been observed in those who have rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and multiple sclerosis (MS). Here, this review aims to highlight the mechanisms of ABCs with lifestyle interventions in AID, especially how immunosenescence affects the pathogenesis of AID and the future of aging-associated lifestyle interventions in immunosenescence of AID.

State of the art and future directions in assessing the quality of life in rare and complex connective tissue and musculoskeletal diseases

Background

As chronic conditions, rare and complex connective tissue and musculoskeletal diseases (rCTDs) significantly affect the quality of life generating an impact on the physical, psychological, social, and economic dimensions of the patients' lives, having implications on the family, changing the lifestyle and interpersonal relationships. Traditionally, generic and disease-specific measures for Quality of Life (QoL) provide valuable information to clinicians since QoL affects healthcare services utilization, predicts morbidities and mortalities, workability, etc. Moreover, the assessment of unmet clinical needs, satisfaction, the experience with the treatment and the care, the psychological dimensions, and the effects of the diseases, such as fatigue, could represent valuable dimensions to be considered in the QoL impact assessment. It is also necessary to measure the impact of rCTDs by considering the perspectives of family members/informal caregivers, for instance considering values, beliefs, experiences, life circumstances, psychological aspects, family relationships, economic issues, changes in social activities, etc.

Objective

The aim of this scoping review is to better understand the status of QoL metrics used in clinical and economic research for the assessment of the individual's perspective on living with rCTDs.

Research question

What are the main challenges in QoL measures (and/or) measurement/assessment in rCTDs?

Materials and methods

Scoping review of the literature referring to QoL measures in rCTDs. Database: PUBMED, ISI-Web of Science; last date: 21/09/2021.

Results

Anxiety and depression, body image satisfaction, daily activity, fatigue, illness perception, pain, personality, QoL, resilience, satisfaction with the relationship, self-management, sexual QoL, sleep quality, social support, stress, uncertainty, and work productivity are the observed dimensions covered by the included studies. However, "more shadows than lights" can summarize the review's outcome in terms of Patient Reported Outcome Measures (PROMs) domains covered for each of the rCTDs. Also, for those diseases characterized by a relatively high prevalence and incidence, such as Systemic Lupus Erythematosus, Sjögren's Syndrome, and Systemic Sclerosis, the analysis of patients' resilience, satisfaction with the quality of the relationship, personality, and stress are still missing dimensions. It has been observed how reducing items, increasing the number of domains, and disease-specific questionnaires characterize the "technological trajectory," such as the evolution of questionnaires' characteristics for assessing QoL and QoL-related dimensions and the burden of rCTDs.

Conclusion

The scoping review presents an overview of studies focused on questionnaires used to evaluate the different dimensions of quality of life in terms of general instruments and disease-specific questionnaires. Future research should include the co-design with patients, caregivers, and patient representatives to create questionnaires focused on the unmet needs of people living with rCTDs.

Neuropsychiatric manifestations in childhood-onset systemic lupus erythematosus

Neuropsychiatric manifestations occur frequently and are challenging to diagnose in childhood-onset systemic lupus erythematosus (SLE). Most patients with childhood-onset SLE have neuropsychiatric events in the first 2 years of disease. 30-70% of patients present with more than one neuropsychiatric event during their disease course, with an average of 2-3 events per person. These symptoms are associated with disability and mortality. Serum, cerebrospinal fluid, and neuroimaging findings have been described in childhood-onset SLE; however, only a few have been validated as biomarkers for diagnosis, monitoring response to treatment, or prognosis. The aim of this Review is to describe the genetic risk, clinical and neuroimaging characteristics, and current treatment strategies of neuropsychiatric manifestations in childhood-onset SLE.

Effects of diet on the outcomes of rheumatic and musculoskeletal diseases (RMDs): systematic review and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). In this paper, the literature on the effect of diet on the progression of RMDs is reviewed.

METHODS

Systematic reviews and meta-analyses were performed of studies related to diet and disease outcomes in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis, psoriatic arthritis, systemic sclerosis and gout. In the first phase, existing relevant systematic reviews and meta-analyses, published from 2013 to 2018, were identified. In the second phase, the review was expanded to include published original studies on diet in RMDs, with no restriction on publication date. Systematic reviews or original studies were included if they assessed a dietary exposure in one of the above RMDs, and reported results regarding progression of disease (eg, pain, function, joint damage).

RESULTS

In total, 24 systematic reviews and 150 original articles were included. Many dietary exposures have been studied (n=83), although the majority of studies addressed people with OA and RA. Most dietary exposures were assessed by relatively few studies. Exposures that have been assessed by multiple, well conducted studies (eg, OA: vitamin D, chondroitin, glucosamine; RA: omega-3) were classified as moderate evidence of small effects on disease progression.

CONCLUSION

The current literature suggests that there is moderate evidence for a small benefit for certain dietary components. High-level evidence of clinically meaningful effect sizes from individual dietary exposures on outcomes in RMDs is missing.

Smoking, alcohol consumption and disease-specific outcomes in rheumatic and musculoskeletal diseases (RMDs): systematic reviews informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). The aim of this paper was to review the literature on the relationship between smoking and alcohol consumption with regard to RMD-specific outcomes.

METHODS

Two systematic reviews were conducted to identify systematic reviews and meta-analyses, published between 2013 and 2018, related to smoking and alcohol consumption in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), systemic sclerosis (SSc) and gout. Two additional systematic reviews were performed to identify original longitudinal studies on smoking and alcohol consumption and disease-specific outcomes.

RESULTS

Nine reviews and 65 original studies on smoking as well as two reviews and 14 original studies on alcohol consumption met the inclusion criteria. While most studies were moderate/poor quality, smoking was significantly associated with poorer outcomes: cardiovascular comorbidity; poorer response to RA treatment; higher disease activity and severity in early RA; axSpA radiographic progression. Results were heterogeneous for OA while there was limited evidence for PsA, SSc and gout. Available studies on alcohol mainly focused on RA, reporting a positive association between alcohol intake and radiographic progression. Five studies assessed alcohol consumption in gout, reporting a significant association between the number and type of alcoholic beverages and the occurrence of flares.

CONCLUSION

Current literature supports that smoking has a negative impact on several RMD-specific outcomes and that moderate or high alcohol consumption is associated with increased risk of flares in RA and gout.

Diet and Hygiene in Modulating Autoimmunity During the Pandemic Era

The immune system is an efficiently toned machinery that discriminates between friends and foes for achieving both host defense and homeostasis. Deviation of immune recognition from foreign to self and/or long-lasting inflammatory responses results in the breakdown of tolerance. Meanwhile, educating the immune system and developing immunological memory are crucial for mounting defensive immune responses while protecting against autoimmunity. Still to elucidate is how diverse environmental factors could shape autoimmunity. The emergence of a world pandemic such as SARS-CoV-2 (COVID-19) not only threatens the more vulnerable individuals including those with autoimmune conditions but also promotes an unprecedented shift in people's dietary approaches while urging for extraordinary hygiene measures that likely contribute to the development or exacerbation of autoimmunity. Thus, there is an urgent need to understand how environmental factors modulate systemic autoimmunity to better mitigate the incidence and or severity of COVID-19 among the more vulnerable populations. Here, we discuss the effects of diet (macronutrients and micronutrients) and hygiene (the use of disinfectants) on autoimmunity with a focus on systemic lupus erythematosus.

The Relationship of Lifestyle with Disease Activity among Patients with Systemic Lupus Erythematosus: A Descriptive-Correlational Study

Objective:

The objective of this study was to evaluate the relationship of lifestyle with disease activity among patients with systemic lupus erythematosus.

Methods:

This cross-sectional descriptive-correlational study was conducted in 2019 on 209 patients with systemic lupus erythematosus. Data were collected using a demographic and clinical characteristics questionnaire, the Health-Promoting Lifestyle Profile II, and the systemic lupus erythematosus disease activity Index. The data were analysed through the mixed model and the logistic regression analyses.

Results:

In total, 67.5% of participants had active disease. The mean score of lifestyle was 2.49±0.30 and the lowest and the highest lifestyle dimensional mean scores were respectively related to the physical activity and the health responsibility dimensions (1.55±0.60 and 3.25±0.45). The analysis showed that each one point increase in the mean score of lifestyle was associated with 0.79 point decrease in the odds of disease activity (P = 0.006). Moreover, disease activity had significant positive relationship with body mass index (P = 0.015).

Conclusion:

Interventions for promoting lifestyle among these patients and improving healthcare providers’ knowledge about Systemic lupus erythematosus and lifestyle modification are recommended to reduce disease activity.

Serum levels of n-3 and n-6 polyunsaturated fatty acids in patients with systemic lupus erythematosus and their association with disease activity: a pilot study

Objective: Polyunsaturated fatty acids (PUFAs) may modulate the inflammatory process in systemic autoimmune diseases, including systemic lupus erythematosus (SLE). The aim of this study was to assess the serum concentrations of essential 18-carbon PUFAs and their long-chain derivatives in patients with SLE and healthy controls, and to analyse their associations with laboratory and clinical features of the disease.Method: n-6 and n-3 PUFA composition was assessed in the sera of 30 SLE patients and 20 healthy controls using gas chromatography-mass spectrometry. We investigated the associations between PUFAs and disease activity measured with Systemic Lupus Erythematosus Activity Index (SLEDAI) scores, erythrocyte sedimentation rate, C-reactive protein, complement C3 and C4 concentrations, anti-nuclear antibody (ANA) titre, anti-double-stranded DNA (anti-dsDNA) antibody concentration, and medications.Results: Serum linoleic acid (LA) and α-linolenic acid concentrations were significantly higher in SLE patients compared with healthy controls. LA concentration correlated positively with the ANA titre and corticosteroid doses; eicosapentaenoic acid (EPA) and docosahexaenoic acid correlated inversely with anti-dsDNA antibody concentration. Patients treated with immunosuppressants had significantly lower concentrations of LA, arachidonic acid, and EPA.Conclusion: Both n-6 and n-3 PUFA precursors can participate in the inflammatory process in SLE patients. The mechanism of the PUFA metabolism disturbance needs further exploration.

Combined aerobic and resistance training improves physical and executive functions in women with systemic lupus erythematosus

OBJECTIVES

Exercise is considered as an adjuvant therapeutic modality to alleviate symptoms of several rheumatic diseases. However, data regarding the benefits of exercise to patients with systemic lupus erythematosus (SLE) are relatively scant.

METHODS

This study aimed to assess the effects of regular, moderate-intensity, aerobic exercise combined with resistance training on women with SLE who had no regular exercise. Patients were recruited and allocated into either the exercise or control group by their willingness. Patients in the exercise group (n = 12) underwent 12 weeks of combined exercise (five days per week), whereas those in the control group (n = 11) maintained their usual lifestyle.

RESULTS

At baseline, there were no between-group differences in body composition, disease activity, two-kilometer walking test, and executive function test. After the combined exercise intervention for 12 weeks, significant improvements of both fitness index and reaction time to the stimuli in the go/no-go test were observed in the exercise group, but not in the control group. The disease activities in both study groups did not change significantly at the end of the study period.

CONCLUSION

Our results suggest that regular moderate-intensity aerobic exercise combined with resistance training improves the physical and executive functions of SLE patients without exacerbating disease activity.

Relationship between disease activity, organ damage and health-related quality of life in patients with systemic lupus erythematosus: A systemic review and meta-analysis

OBJECTIVES

Systemic lupus erythematosus (SLE) is a common systemic autoimmune disease that may lead to considerable physical, psychological, and socioeconomical burden. In previous studies, inconsistent results were reported for the association of disease activity and organ damage with health-related quality of life (HRQoL). This paper aimed to explore the relationship between disease activity, organ damage, and HRQoL measured by SF-36, EQ-5D, LupusQoL, and LupusPRO and investigate whether the correlation is region-specific.

METHODS

We systematically searched for studies reporting the association between SLE disease activity, organ damage, and HRQoL in MEDLINE, EMBASE, PsycINFO, World of Science, the Cochrane Library, and CINAHL from inception to December 2019. A meta-analysis and region subgroup analysis were performed with a random-effects model to estimate pooled correlation coefficients and heterogeneity.

RESULTS

Forty articles were included representing of 6079 adult SLE patients. The meta-analysis of SF-36 and LupusPRO studies revealed mild to moderate negative correlations between disease activity and domains of these HRQoL measurements (correlation coefficient r ranging from -0.27 to -0.07). Likewise, negative correlations were found between organ damage and domains of SF-36 and LupusPRO (r ranging from -0.25 to -0.08). The pooled correlation coefficient is relatively higher in physical functioning related domains than mental health. In the region subgroup analysis, disease activity had strong negative correlations with SF-36 domains in African and European SLE patients, while organ damage had the strongest negative correlation with SF-36 domains in Asian SLE patients (p < 0.010).

CONCLUSION

This study provides the first comprehensive assessment of the relationship between disease activity, organ damage, and four popular HRQoL instruments, which provides useful insight into the target therapy in SLE management.

Immunomodulatory Effects of Diet and Nutrients in Systemic Lupus Erythematosus (SLE): A Systematic Review

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by multiple organ involvement, including the skin, joints, kidneys, lungs, central nervous system and the haematopoietic system, with a large number of complications. Despite years of study, the etiology of SLE remains unclear; thus, safe and specifically targeted therapies are lacking. In the last 20 years, researchers have explored the potential of nutritional factors on SLE and have suggested complementary treatment options through diet. This study systematically reviews and evaluates the clinical and preclinical scientific evidence of diet and dietary supplementation that either alleviate or exacerbate the symptoms of SLE. For this review, a systematic literature search was conducted using PubMed, Scopus and Google Scholar databases only for articles written in the English language. Based on the currently published literature, it was observed that a low-calorie and low-protein diet with high contents of fiber, polyunsaturated fatty acids, vitamins, minerals and polyphenols contain sufficient potential macronutrients and micronutrients to regulate the activity of the overall disease by modulating the inflammation and immune functions of SLE.

Dietary Habits in Patients with Systemic Lupus Erythematosus

Patients with systemic lupus erythematosus (SLE) are often interested in which diets to follow. Our aim was to investigate which dietary habits were common among our patients, and which of them were in correlation with laboratory parameters of disease activity, such as complement values and 24-h proteinuria. This study included 76 patients with SLE in clinical remission with a 6-month flare free period. They completed a specialized, self-administered, 23-item food frequency questionnaire about their weekly dietary habits. Basic anthropometric data, levels of C3 and C4, and 24-h proteinuria were recorded and analyzed with respect to their dietary habits. The majority of patients had a normal body mass index of 18.5-25 kg/m², and worked out regularly. The most frequently consumed foods reported by the patients were fruits, milk, vegetables, meat, pasta, rice, and bread. Decreased values of C3 were found in 34 (44.7%) patients, and decreased values of C4 in 28 (36.8%) patients. Decreased values of C3 were found in patients who often consumed meat (P = .015), and decreased values of C4 in patients who often consumed fast food (P = .043). Patients who often consumed fast food demonstrated a decreasing trend of C3 (P = .060), and patients who often consumed fried food had a decreasing trend of C4 (P = .051). Significant correlation between daily proteinuria and dietary habits was not found. Dietary habits can influence the disease course of SLE. Our study confirms that decreased levels of complement compounds C3 and C4, which are possible predictors of disease activation, are associated with frequent consumption of low quality proteins and food rich in calories.

Tobacco smoking is an independent factor associated with retinal damage in systemic lupus erythematosus: a cross-sectional and retrospective study

To analyze the influence of tobacco smoking on systemic lupus erythematosus (SLE) clinical features and damage. Cross-sectional and retrospective, case-control study comparing SLE patients with and without tobacco exposure. Cumulative clinical data and comorbidities were collected, and severity (Katz index) and damage (SLICC/ACR damage index) (SDI) indices were calculated. Pack-years (PY) was used to estimate lifetime tobacco exposure. A logistic regression was carried out to explore the impact of tobacco use on retinal damage. 216 patients were included. The mean age was 49 years (± 12.7), 93% were females, and median disease duration was 17 years [interquartile range (IQR):9-25]. Fifty-three percent of patients were smokers at some point. The median PY was 13 (IQR: 6-20.5). Only 54.8% of active smokers recalled having been informed of the negative effects of smoking, versus 83.3% of never smokers (< 0.001). In a bivariant analysis, an association between tobacco use at any time and discoid lupus [OR: 3.5(95%CI 1.5-8.9); p = 0.002] photosensitivity [OR: 2.06(95%CI 1.16-3.7); p = 0.01] and peripheral arteriopathy (p = 0.007) was found. Considering SDI item by item, a significant association with retinal damage, adjusted for age [OR: 1.03(95%CI 1-1.07); p = 0.04], was found. Using PYs, an association was found with discoid lupus (p = 0.01), photosensitivity (p = 0.03) and peripheral arteriopathy (p = 0.01), global SDI > 0 (p = 0.002) and retinal damage (p = 0.02). In a multivariate analysis exploring factors associated with retinal damage, any previous smoking history and SDI remained associated with retinal damage. Tobacco smoking is associated with cutaneous manifestations and damage and is an independent predictor of retinal damage in SLE patients.

Physical activity, sedentary behaviour and their associations with cardiovascular risk in systemic lupus erythematosus

Objective

Using a novel isotemporal substitution paradigm, this study aimed to estimate the cross-sectional associations of objectively measured sedentary behaviour and physical activity (PA) with cardiovascular risk factors among patients with SLE.

Methods

This was a cross-sectional study of adult SLE patients without documented cardiovascular disease (CVD). Cardiovascular risk factors were measured, including BMI, blood pressure, fasting glucose and lipid profile. Ten-year CVD risk was estimated using the American College of Cardiology/American Heart Association risk assessment tool. Time in sedentary behaviour, light PA, and moderate–vigorous PA (MVPA) was measured by accelerometry. We used three linear regression models—single-activity models, partition models, and isotemporal substitution models—to evaluate the associations of time spent at each movement intensity with each CVD risk variable.

Results

There were 100 SLE patients [92% female; mean (s.d.) age 52.4 (14.4) years]. Only 11 participants adhered to current PA recommendations (⩾150 MVPA min/week in ⩾10-min bouts). In isotemporal substitution, reallocating 10 min from sedentary behaviour to MVPA was associated with lower systolic (β = –2.15 mmHg; P = 0.01) and diastolic blood pressure (β = –1.56 mmHg; P = 0.01), as well as lower estimated 10-year CVD risk (RR 0.81, 95% CI 0.70, 0.93). Time reallocation from light PA to MVPA was associated with lower diastolic blood pressure (β = –1.45 mmHg; P = 0.01) and lower 10-year CVD risk estimates (RR 0.80, 95% CI 0.69, 0.94).

Conclusion

Given that reallocating time from other movement intensities to MVPA is associated favourably with lower cardiovascular risk, PA interventions are needed to address suboptimal MVPA levels among SLE patients.

Pemphigus foliaceus patients (Fogo Selvagem) treated with kinesiotherapy presented lower levels of proinflammatory cytokines

Fogo Selvagem (FS) is a rare autoimmune disease characterized by acantholysis and inflammation of the epidermis. It was evidenced in this disease the increase of proinflammatory cytokines levels which can be influenced by physical activities. Kinesiotherapy, as physiotherapeutic interventions, was associated improvement levels of the quality of live, mainly the pain. Understanding the impact of such methodology in immunology of the FS, may constitute an alternative and effective approach. We compare the levels of serum cytokines and chemokines between nine patients with FS submitted to kinesiotherapy for 12 weeks and ten patients not submitted to kinesiotherapy. The kinesiotherapy was composed by self-stretching followed by a resistance training for upper and lower limbs. The protocol was carried out in three sections of eight to ten repetitions with 70% of the maximum load measured by test maximum of ten repetitions. After strengthening period patients performed a passive stretching. The training sessions lasted 50 min and were performed 3 times a week at least 12 weeks. Cytokines and chemokines were assessed in plasma using enzyme-linked immunosorbent assay and/or cytometric bead array. Patients with FS were being kinesiotherapy presented minors levels of interferon-γ, interleukin (IL)-17, IL-22, and IL-15 when compared to those not submitted to kinesiotherapy. No differences were observed for the detection of the chemokines chemokine ligand (CCL)-2, CCL-3, CCL-5, CCL-11, C-X-C motif chemokine 8 (CXCL-8), and CXCL-10. These results suggest that kinesiotherapy had a positive impact on inflammatory markers that are associated with disease worsening in FS.

Significance and impact of dietary factors on systemic lupus erythematosus pathogenesis

Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology, although its mechanisms involve genetic, epigenetic and environmental risk factors. Considering that SLE pathogenesis is yet to be explored, recent studies aimed to investigate the impact of diet, in terms of triggering or altering the course of the disease. To study the impact of diet on SLE pathogenesis, we conducted a search on Pubmed using the keywords 'diet and autoimmune diseases', 'diet and lupus', 'caloric restriction and lupus', 'polyunsaturated fatty acids and lupus', 'vitamin D and lupus', 'vitamin C and lupus' 'vitamin E and lupus' 'vitamin A and lupus' 'vitamin B and lupus', 'polyphenols and lupus', 'isoflavones and lupus', 'minerals and lupus', 'aminoacids and lupus', 'curcumin and lupus' and found 10,215 papers, from which we selected 47 relevant articles. The paper clearly emphasizes the beneficial role of personalized diet in patients with SLE, and the information presented could be used in daily practice. Proper diet in SLE can help preserve the body's homeostasis, increase the period of remission, prevent adverse effects of medication and improve the patient's physical and mental well-being.

Use of Physical Activity Monitors in Rheumatic Populations

PURPOSE OF REVIEW

The purpose of this review paper is to provide an overview of the recent research using physical activity monitors in rheumatic populations including those with osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, and fibromyalgia.

RECENT FINDINGS

Recent research demonstrates increased use of physical activity monitors in these populations, especially in those with osteoarthritis. Results from cross-sectional, longitudinal, and intervention studies highlight that physical activity levels are below recommended guidelines, yet evidence suggests benefits such as improving pain, fatigue, function, and overall well-being. While the use of physical activity monitors in rheumatic populations is increasing, more research is needed to better understand physical activity levels in these populations, the effects of activity on relevant clinical outcomes, and how monitors can be used to help more individuals reach physical activity guidelines.

Self-Reported Physical Activity Is Associated with Lupus Nephritis in Systemic Lupus Erythematosus: Data from KORean Lupus Network (KORNET) Registry

PURPOSE

The aim of this study was to identify the associations among physical activity, disease activity, and organ damage in patients with systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

A total of 415 patients with SLE were consecutively enrolled from the KORean lupus Network (KORNET) registry. This registry assessed clinical features, disease activity [Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K)], and organ damage [Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (SDI)] upon enrollment in the study. Self-reported physical activity was measured by the International Physical Activity Questionnaire. Statistical analyses were conducted using the Mann-Whitney U test and multivariate logistic regression analysis.

RESULTS

A significant difference in vigorous activity was noted between patients with lupus nephritis (LN) (n=93) and those without LN (n=322) (p=0.012), but not in moderate and walking activities. In contrast, no differences in physical activity, walking, moderate, and vigorous intensity, according to SLEDAI-2K and SDI were found. In addition to younger age (p=0.032), high physical component summary of SF-36 (p=0.004) and SLEDAI-2K (p=0.038), and less vigorous physical activity were associated with LN (p=0.024). However, cardiovascular disease was not associated with physical activity in SLE patients.

CONCLUSION

This study showed that patients with LN had less vigorous physical activity than patients without LN. The results suggest that lupus nephritis might be associated with physical activity.

Systemic Lupus Erythematosus in Primary Care: An Update and Practical Messages for the General Practitioner

Systemic Lupus Erythematosus (SLE) is a complex chronic autoimmune disease that manifests a wide range of organ involvement. Traditionally, the diagnosis and management of SLE is provided at secondary and tertiary centers to ensure prompt initiation of treatment, adequate control of flares and prevention of irreversible organ damage. Notwithstanding, the role of primary care in SLE is also emerging as there are still significant unmet needs such as the diagnostic delay at the community level and the high burden of therapy- and disease-related comorbidities. In the present review, we summarize practical messages for primary care physicians and general practitioners (GPs) concerning early diagnosis and proper referral of patients with SLE. In addition, we discuss the main comorbidities complicating the disease course and the recommended preventative measures, and we also provide an update on the role and current educational needs of GPs regarding the disease.

Increased flexibility, pain reduction and unaltered levels of IL-10 and CD11b + lymphocytes in patients with systemic lupus erythematosus were associated with kinesiotherapy

The effect of physical activity on the immune system is still poorly understood in cases of systemic lupus erythematosus (SLE). Therefore, our aim was to investigate differences in the serum levels of cytokines (IL-2, IL-5, IL-6, IL-8, IL-10 and TNF-α) and the numbers of CD11b + and CXCR2 + neutrophils and lymphocytes in women with SLE undergoing drug treatment, without ( n = 9) or with ( n = 5) 4 months of kinesiotherapy. Parameters related to functional capacity were also analyzed. In the case of the patients who were not submitted to kinesiotherapy, there were reductions in the levels of IL-5, IL-6 and IL-10, and an increase in the number of CD11b + leukocytes, in addition to an increase in abdominal circumference after the monitoring time. Patients submitted to kinesiotherapy did not present changes in serum cytokines or in the numbers of CD11b + and CXCR2 + neutrophils and lymphocytes, but there were increases of flexibility and strength, as well as a reduction in pain sensation after the monitoring time. In conclusion, kinesiotherapy was able to increase flexibility and reduce pain in SLE patients without influencing immune parameters.

Physical activity and sedentary behavior in patients with systemic lupus erythematosus and rheumatoid arthritis

Objective

Patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD). As sedentary behavior and lack of physical activity are known cardiovascular risk factors, we compared habitual activity between SLE patients, RA patients, and healthy control participants.

Patients and methods

For this cross-sectional study, RA and SLE patients were recruited from rheumatology clinics at an academic medical center from April 2013 to December 2014. Healthy control participants were recruited through local advertising during the same time period. Habitual activity was measured using a triaxial accelerometer worn during waking hours for 7 consecutive days. Minutes per day of sedentary, light, and moderate–vigorous physical activity (MVPA) were recorded and compared between SLE, RA, and healthy participants using ANOVA.

Results

There were 59 participants included in the analysis: 20 SLE patients, 19 RA patients, and 20 healthy controls. Disease activity was quiescent in both the SLE and RA groups. All three groups demonstrated high sedentary behavior (mean ± SD sedentary time for all participants: 10.1±1.3 hours/day; 76.4% total wear time). There were no significant differences between SLE, RA, and healthy participants in time spent in sedentary behavior (p=0.80) or light activity (p=0.17). Total MVPA (mean ± SD, minutes/day) was significantly lower in SLE (34.5±22.7; p<0.001) and RA (41.5±21.3; p=0.005) patients compared to controls (64.9±22.4).

Conclusion

SLE and RA patients demonstrate suboptimal MVPA despite well-controlled disease. Given their increased CVD risk, effective interventions are required to improve habitual physical activity levels in both populations.

Do adverse pregnancy outcomes contribute to accelerated cardiovascular events seen in young women with systemic lupus erythematosus?

Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal-placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.

Pain rather than self-reported sedentary time explains variation in perceived health and activity limitation in persons with rheumatoid arthritis: a cross sectional study in Sweden

To investigate (1) the amount of self-reported time spent sedentary among a large cohort of persons with rheumatoid arthritis (RA), and (2) the contribution of sedentary time to explain perceived health and activity limitation in RA beyond that of previously known correlates. This cross-sectional study used data from a postal questionnaire and the Swedish Rheumatology Quality registers (SRQ). The International Physical Activity Questionnaire was used to assess sedentary time (sitting) and moderate, vigorous and walking activity (MVPA). Sociodemographics, pain, fatigue, fear-avoidance beliefs, anxiety/depression, disease duration, MVPA and sedentary time were included in multiple regression models with perceived health (Visual Analogue Scale 0-100) and activity limitation (Stanford Health Assessment Questionnaire) as dependent variables.

RESULTS

In all 3152 (59%) of 5391 persons identified as eligible from the SRQ, responded to the questionnaire. 2819 individuals with complete data on all study variables were analysed. Mean time (SD) spent sedentary was 257 (213) minutes per day. Sedentary time did not contribute significantly to explain perceived health and only minimally to explain activity limitation. Instead, variation was mainly explained by pain; for perceived health (Beta = 0.780, p < 0.001) and for activity limitation (Beta = 0.445, p < 0.001).The results indicate a non-significant role of sedentary time and a need for increased focus on pain in the management of RA. Future studies should use prospective designs and objective assessment methods to further investigate the associations between sedentary time and health outcomes in persons with RA.

The Effectiveness of Exercise in Adults With Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis to Guide Evidence-Based Practice

BACKGROUND

Fatigue is the most common and unpleasant symptom of patients with systemic lupus erythematosus (SLE). However, there is limited information regarding how exercise affects fatigue.

AIMS

The purpose of this study is to review and synthesize the current knowledge concerning the effectiveness of exercise training for treating fatigue among adults with SLE. The characteristics of beneficial exercise training are further evaluated.

METHODS

We conducted a systematic review and meta-analysis. The databases searched were MEDLINE, CINAHL, PEDro, Cochrane Library, Scopus, and PQDT from their inception to February 3, 2016. The quality of each selected study was assessed using the PEDro scale. A between-group analysis was performed to evaluate the effectiveness of the exercise training. Data were analyzed using the Cochrane Collaboration's RevMan 5.3 (Copenhagen, Denmark).

RESULTS

Two randomized controlled trials and one quasiexperimental study were included in this systematic review and meta-analysis. Aerobic exercise, three times a week and of moderate intensity, was a common component of the three studies. Two studies were conducted in a supervised setting and one study was based at home. One study lasted 8 weeks and two studies lasted 12 weeks. The meta-analysis showed that aerobic exercise could decrease fatigue (MD = -.52, 95% confidence interval [CI] [-.91, -.13], p = .009) and increase vitality (MD = 14.98, 95% CI [7.45, 22.52], p < .001). The subgroup analysis indicated that 12 weeks of exercise training and exercise under a supervised setting significantly benefited fatigue.

LINKING EVIDENCE TO ACTION

The pooled data indicate that 12 weeks of an aerobic exercise program that is supervised by health professionals could reduce fatigue and increase vitality for patients with SLE. SLE patients with mild disease should begin with moderate intensity for at least 20 minutes, 3 days a week.

An update on diet and nutritional factors in systemic lupus erythematosus management

Systemic lupus erythematosus (SLE) is a chronic inflammatory and autoimmune disease characterised by multiple organ involvement and a large number of complications. SLE management remains complicated owing to the biological heterogeneity between patients and the lack of safe and specific targeted therapies. There is evidence that dietary factors can contribute to the geoepidemiology of autoimmune diseases such as SLE. Thus, diet therapy could be a promising approach in SLE owing to both its potential prophylactic effects, without the side effects of classical pharmacology, and its contribution to reducing co-morbidities and improving quality of life in patients with SLE. However, the question arises as to whether nutrients could ameliorate or exacerbate SLE and how they could modulate inflammation and immune function at a molecular level. The present review summarises preclinical and clinical experiences to provide the reader with an update of the positive and negative aspects of macro- and micronutrients and other nutritional factors, including dietary phenols, on SLE, focusing on the mechanisms of action involved.