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by Christiana Logan, Dietetic Intern, Tufts University

Sjögren’s is an autoimmune disease where immune cells attack exocrine glands (salivary, sweat, lacrimal glands, etc.) leading to the most common symptoms of dry mouth, dry eyes, and dry skin. Extra-glandular manifestations can also be present. Sjögren’s also can cause digestive system difficulties such as difficulty eating (dysphagia), GERD (Gastro-Esophageal Reflux Disease), acid stomach (dyspepsia), and dysfunction of the pancreas and the liver which are essential for digestion and absorption of nutrients. Although these symptoms have the potential to affect nutritional status, the good news is that specific nutrition and diet changes can greatly improve Sjögren’s symptoms.

Decreased salivary flow (xerostomia) has been shown to impact the dietary choices of Sjögren’s sufferers. Individuals who experience severe xerostomia tend to avoid crunchy foods such as raw vegetables, dry or tough foods such as meats and breads, and sticky foods such as peanut butter. Xerostomia can also affect dental health. Saliva contains enzymes that break down sugars in the things we eat, buffers that neutralize acid and minerals to remineralize teeth. In the absence of saliva, sugars stick to the teeth and increase bacterial proliferation and dental decay. Poor oral health in the form of missing or highly diseased teeth can cause patients to choose softer, more carbohydrate-rich foods that are easier to chew. Since symptoms like dry mouth can lead to individuals choosing a limited variety of tolerable foods, it is extremely important to focus on maintaining a healthy diet. This means having a variety of fruits and vegetables, lean meats and/or vegetable proteins, whole grains, healthy fats, and avoiding saturated fat, added sugars, and excess sodium as much as possible. This can often be difficult given the rough textures of vegetables and other nutritious foods.

Additionally, in an effort to relieve symptoms of dry mouth, many people find themselves constantly sipping on beverages throughout the day. Sugar containing beverages like soda, juice, sweetened iced tea, coffee beverages and any acidic beverages can promote tooth decay and dental enamel erosion, so it is best to avoid these. Even sipping on water washes away any saliva produced and diminishes its protective effect. So, try to use alternatives to drinking fluids like xylitol gums and salivary stimulants to relieve dry mouth symptoms.

Several strategies can help improve the palatability of nutritious foods. Increase protein intake by cooking using moist cooking methods like baking in liquid, boiling, and slow cooking or pressure cooking. Incorporate meats into soups or sauces, add Greek yogurt to smoothies or dips, and try seafoods like fish and shellfish as they tend to be softer. Increase vegetable intake by adding a variety of them to soups, stews, and smoothies, cooking them well and consuming them mashed, or juicing them. Other recommendations include increasing omega-3 fatty acid intake by having fatty fish like salmon several times per week and incorporating healthy oils like olive and flaxseed oils.

Nutritional management of Sjögren’s symptoms is not well studied, however, there is evidence that in- creased intake of antioxidants like omega-3 fatty acids and vitamin E can have a positive effect on salivary output, dry eye, and inflammation. Omega-3 fatty acids can be found in food sources such as fish like tuna, salmon, and mackerel (consumed raw or canned), nuts like walnuts, peanuts, peanut butter, and oils like canola, flaxseed, and walnut oil. Vitamin E can be found in foods such as sunflower seeds, almonds, almond butter, avocados, spinach, butternut squash, broccoli, olive oil, trout, and shrimp, to name a few. Omega-3 fatty acids and vitamin E are also available in supplement form from your local supermarket or online. When purchasing supplements, be sure to purchase them from a reputable source, and from companies labeled with the USP verification. For dosage and safety information, please consult your dietitian or doctor before starting a new dietary supplement.

Other symptoms of Sjögren’s like gastroesophageal reflux disease (GERD) have been more thoroughly studied and can be well controlled by changing the diet. GERD is a syndrome that is defined by the backward flow of stomach acid into the esophagus or even into the mouth. This condition is caused by overproduction of stomach acid, or a weak junction were the esophagus meets the stomach. GERD can be diagnosed by a physician based on the presentation of symptoms including heartburn, bad breath, coughing, abdominal pain, nausea or vomiting. GERD affects 60% of Sjögren’s sufferers, a much higher percentage compared to 23% of the general population.

Lifestyle changes that may alleviate symptoms include quitting smoking, losing weight (if overweight), walking after meals, and sleeping with the head of bed elevated. Additional nutritional recommendations for improving GERD symptoms include:

  • Avoiding fatty foods
  • Choosing lean protein sources like poultry, fish, tofu, and beans
  • Avoiding foods that tend to exacerbate symptoms including alcohol, caffeine, acidic foods, and spicy foods
  • Avoiding large meals, and consuming smaller, more frequent meals throughout the day

In summary, the symptoms related to Sjögren’s can affect the diet, and consequently overall health and wellbeing. Dietary changes can improve symptoms, and associated quality of life. Adapting to Sjögren’s often means limited dietary choices, however, this can lead to malnutrition and weight loss. Try to maintain a varied diet, rich in fruits and vegetables and proteins. Since antioxidants like omega-3 fatty acids and vitamin E in the diet may improve symptoms of dry mouth and inflammation, focus on having more salmon and other fatty fish, as well as nuts and oils to help improve symptoms over time. Be sure to talk to your doctor if you are experiencing symptoms of GERD or other gastrointestinal complications. For further help, ask your doctor to refer you to a Registered Dietitian who can give you guidelines specifically tailored to your needs.

This article was first printed in  the Foundation's patient newsletter for members. Click here to learn more about becoming a member.