Lupus

By Dr. Tim Trader ND, PhD

Those with lupus probably have a good understanding of what is going on with them, at least in part. But for those who this is new for them, here is a quick explanation of what is happening when we say the word lupus. There are several types of lupus, they all come under one umbrella term called systematic lupus erythematosus (SLE), where the body has an immune response as autoantibodies see a person’s own tissues as something similar to a substance the body has tried to eliminate at some point previously. Lupus can affect the skin as in cutaneous lupus, the kidneys which have been called lupus nephritis, lupus can also affect the muscles, bones and joints. Nothing is resistant to lupus, it can cause impairment in the blood, the heart, the lungs, the eyes, the reproductive system, and even the nervous system (which is called neuropsychiatric systemic lupus erythematosus). It is said that 1.5 million Americans have lupus and that over 5 million people in the world have lupus. Sounds pretty serious, doesn’t it? The reality is that it can be turned around.

There are several possible causes and officially it is thought that the cause is unclear, because the situation can be multifaceted, it can be hard to pin down just one cause. To understand why lupus is affecting so many people you have to look at a bigger picture. The first place most science turns to is genetics and there has been some correlation with certain genetic single nucleotide polymorphisms (SNPs), but there has not been found one genetic cause. Some people who have suspected genetics may never experience a problem, it takes contact with something in the environment, or something eaten or an effect of a lifestyle that may trigger the rise of lupus. There are people who possess no genetic or family ties to lupus and still they are affected by this autoimmune disease. What is the deciding factor?

Sometimes it takes some time to find out if you do have lupus. The tests for Lupus are to check for antibodies (1), the problem is that these antibodies are not specific to lupus but will tell us that there is an autoimmune condition, and it can take a well-trained physician to not only look at the tests, but also put together the whole puzzle, which includes symptoms and possible risk factors. Sometimes it may take several different diagnosticians until finally one finds out just what the problem is. Some never find the proper diagnosis, yet they change their lifestyle habits, and the symptoms diminish or go away completely. Finding the cause or causes and reversing or removing it is the real solution.

Unhealthy practices

Smoking and alcohol consumption top the list of what most people consider unhealthy practices, and they at least do not help to alleviate the symptoms of lupus. Smoking is known to cause DNA damage, and this damage has been associated with autoantibodies that affect Lupus (2). And no surprise that moderate alcohol consumption has been associated with being a lupus risk factor (3). This is just the start of it. Inactivity has been shown to at least make lupus or the symptomology worse, (4,5) though exercise can be difficult for some with lupus.  Environmental toxins also influences the immune function of the body and how it reacts to invaders (6). This includes everything from air pollution to the cleaning products in your home. You can’t forget about sleep, being sleep deprived can be a major factor in originating lupus (7). Half the people with lupus have a problem with sleep (8). Sleep deprivation just racks havoc with your immune system (9), you need your sleep to stay healthy.

What you eat plays a critical role in Lupus

What is called the western diet (what most people eat in our modern culture) may be one of the most important factors in creating lupus and then a change in diet may put it into remission. A diet full of processed foods (10), high in fat and fried foods (11,12, 13,14,15), and animal products (16) can start a cascade of reactive factors for the immune function of your body creating a perfect scenario for lupus to start and thrive. A diet low in nutrients (17) and high in toxic chemicals really plays a major role in creating lupus (18). Even some thought to be healthy foods can put the immune function of the body into high alert and possibly explain a rise in lupus, like gluten from wheat products (19), or casein from dairy (20,21). Sometimes a whole protein from the food, can get though into our blood stream, where the body sees it as an intruder, and it activates the immune function of the body to get rid of it (22). Normally only amino acids get into our blood systems after a protein has been fully digested (23). This unwanted protein can look like some protein in a cell in an organ, this ends up as what is called molecular mimicry, and the granulocyte (immune cells) can attack proteins in our own cells or organs which are mistaken for the intruder and this leads to an autoimmune disease like lupus. (24)

This is where the problems in the gut microbiome (beneficial bacteria) and digestive system are caused by the western diet (25,26). The western diet disrupts the environment of our digestive system, causing some beneficial bacteria to die and some opportunistic bacteria to thrive (27). This leads to something called dysbiosis, which is literally chaos in our digestive system, and it not only affects our digestive system, but it also affects our health in many ways (28). Even just having a diet that is high in processed oils can create dysbiosis all by itself (29).

One of the consequences of the western diet is that it causes something called Intestinal permeability or a better way to say it, is that your gut is leaking (30,31). This is the reason how some proteins can get into our blood stream when they are never supposed to be there. Intestinal permeability has been linked to lupus (32). This is where we see how gluten from grain products and casein from dairy can be a direct cause of lupus (33,34) as they disrupt the gut microbiome and cause intestinal permeability causing whole proteins to enter the blood stream and causing the molecular mimicry after the immune response now sees these proteins as threats either from the undigested proteins in our blood system or in a cell. But they are not the only things that get into our blood stream from our digestive system that are not supposed to be there. One of the opportunistic bacteria is Escherichia coli, better known as E. Coli and it can produce a toxin called lipopolysaccharide (LPS) and when the intestinal barrier is compromised LPS can and does get into our bodily systems and can cause some inflammatory damage and can start an autoimmune cascade (35). Yes, intestinal permeability and LPS have been found to be a major factor in creating lupus (36).

A healing diet

Changing what you eat can make the biggest difference in how your body deals with and reduces, even alleviates the symptoms of lupus like introducing more whole plant foods (37). First of all, a low-fat diet of whole plant foods, high in fiber, can make a healthy gut microbiome (38) and repair intestinal permeability (39). Thus, keeping food particles that were never made to be in our blood stream from getting into our systems and causing havoc. Without healing the gut, you can never put any autoimmune disease into remission.

But a proper diet is not just about healing the gut, it is about healing the effects of lupus and turning it around. Just a plant-based diet has been shown to improve lupus all by itself (40). The high antioxidants in a plant exclusive diet can be amazing in healing the oxidative stress that accompanies lupus (41). As can plant exclusive phytochemicals like polyphenols (42) and flavonoids (43). The phytochemicals are notably helpful in reducing the tissue damage that occurs with lupus, like the endothelial dysfunction of the circulatory system.

Sulforaphane and inflammation (44)  

Let’s look closer at individual aspects of a plant exclusive diet and how it affects Lupus. Let’s start with cruciferous vegetables. One unique nutrient found in the Brassicaceae family of vegetables is sulforaphane, but only if you cut it up before cooking it or if you eat it raw, because sulforaphane is created when the plant chemicals, glucoraphanin comes in contact with myrosinase during cutting or chewing, but not after being cooked. There is a transcription factor called Nrf2, which is a major regulator of antioxidants in our bodies (45). Sulforaphane is an activator for Nrf2 (46) which reduces inflammatory cytokines (the overzealous peptides of the immune function of the body) and diminishes the inflammation and allows mending of the cells affected by lupus. Cruciferous vegetables also have been shown to increase glutathione levels in the body (47). Glutathione, the powerful antioxidant that our body makes, and it has been shown to protect the cells affected by the autoimmune onslaught and to clear out the damage (48,49).

Minerals and Lupus  

Simple nutrients that we can be low on can make a difference. Take magnesium for instance, over 50 % of Americans are magnesium deficient (50). Those with lupus have shown to have decreased magnesium levels and with a lower magnesium they have more pain (51). Magnesium is essential for the body’s immune response and with lupus and other autoimmune diseases you need every bit of help you can get to have a healthy immune function (52). A Selenium deficiency has also been found in people with lupus (53), again especially those with severe pain. (54) Selenium is another mineral that can really help those with lupus. Selenium has been shown to reduce overactivated immune cells, specifically the white blood cells called B lymphocytes. (55) It also calms the reaction to lipopolysaccharides (LPS) from the bacterial waist that was never meant to get through the intestinal wall to start with (56).

Too much iron on the other hand can cause a problem for a body trying to deal with lupus. Especially heme-iron from a diet with meat. Heme-iron, which is hard to get rid of, (57) can cause an overload of heme-iron in the body and this elevates CD71 or transferrin receptor on our cells which allows more iron into cells. This impairs T-cell function (58) and can impair mitochondria (the energy systems of the cell) which makes the cell not function as it should contributing to lupus. (59)

Omega 3s fatty acids and lupus

One of the biggest nutrients that almost all of those who are suffering with lupus are severely insufficient in, is omega 3 fatty acids, commonly called the good fats (60). 68% of adults are deficient in omega 3 fatty acids (61). Omega 3s are a game changer for those with lupus, omega 3s reduce inflammation and reduce the immune escalation (62). With lupus, the cytokines are imbalanced with Th2 cytokines dominating the Th1 cytokines. Cytokines are released by T-helpers cells or lymphocytes and when your Th1 and your Th2 cytokines are in balance they work like a control burn in the forest, taking out the stuff that doesn’t belong there. When Th2 cytokines are heightened, without the balance with the Th1 cytokines, the Th2 cytokines become like a forest fire, indiscriminately scorching the landscape and omega 3s put out the fire by bringing the balance back between the cytokines (63).

The situation with omega 3s is that most people associate omega 3s with eating fish. So, the first reaction is to eat some fish or take some fish oils. But the fish have high amounts of heavy metals, like mercury (64) and also have toxic chemicals in them (65,66) and so do the fish oils that are touted as the best way to get your omega 3s (67,68). Mercury has been associated with being a risk factor for lupus (69). As has chemical toxins been found to be a major inciter in lupus and an exacerbator as well (70). The cleanest way to get your omega 3s is from plant foods, the highest foods in alpha linolenic acid (ALA), the base of all omega 3s, is in chia and flax seeds. Other plant foods also have ALA, like walnuts and hemp seeds, and you also find ALA in green leafy vegetables to fruits, it is in most plant foods. The more plants you eat the more omega 3s you get.

The omega 3 fatty acids that have been most helpful for lupus are the longer chain omega 3s, eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA) (71). The body converts the short chain ALA to the longer chain EPA and DHA all by itself (72). Though some people have a bit of a problem in converting the short chain omega 3 to the longer chain EPA and DHA. Most of the time it is due to high amounts of omega 6 fatty acids in the diet (73) Too many omega 6s (found in plant oils primarily) can block the conversion of ALA to DHA. To know for sure that you are converting your ALA to DHA, all you have to do is a simple blood test. Knowing you are getting the full spectrum of omega 3s can make the difference in recovery. EPA/ DHA can increase deficient glutathione (74). EPA/DHA can also help raise other antioxidants levels as well (75) because we don’t use the antioxidants up so readily if we have enough omega 3s.

Flax and chia seeds are not just good for their omega 3s, but they also have something called lignans. Lignans are polyphenols which act as antioxidants but also can help in hormone metabolism. The lignans help to protect the injured cells from the overly aggressive immune function caused by the autoimmune attack called lupus (76). Lignans block what is called platelet-activating factor at the cell receptor site keeping your platelets in your blood from bunching up and causing inflammation and thus, keeping your lupus from getting out of hand. (77) Lignans are something you don’t find in fish.

Toxins and lupus

Like the mercury found in fish, other toxins play havoc with the immune function of the body and affect lupus (78,79). Everything from pesticides that you use in the garden and the pesticides on your food (80) to cleaning chemicals in your house that can impact lupus (81,82). Including personal care products and laundry detergents. (83) Getting rid of the toxic chemicals in your house can have a big impact on keeping lupus from flaring up as well as eating an organic whole plant food diet. Chemicals can even impact your gut microbiome causing high amounts of pathogenic bacteria and low amounts of beneficial bacteria which mentioned earlier is called dysbiosis, which can cause holes in your digestive system which is called intestinal permeability (84). And chemicals can disrupt your hormones, like the xenoestrogens, found in plastics like BPA (85). Xenoestrogens not only create a fake estrogen dominance, they also are immune dysregulating (86).

There is a great link between estrogens and lupus (87). Though we start to see lupus as early as the teen years in girls when estrogens are increasing (88) it is also seen though the menopause years (89). Lupus occurring during postmenopause is called late-onset lupus (90) all of which is started long before menopausal symptoms manifest.  Lupus has a greater percentage in those who are obese and those with a high BMI (body mass index) because of having excess body fat, (91,92) the excess body fat creates a higher rate of estrogens. (93) Estrogens can influence cytokine production (94) or in other words, over production of autoantibodies. High levels of estrogens increase the severity of lupus (95,96) and this is why women predominantly have to deal with lupus. So, having to minimize chemical estrogens and balancing your hormone with diet (97) can make a big difference.

Another environmental factor that can cause problems are vaccines (98,99). Vaccines can create a situation of molecular mimicry (100) as was talked about before. Where vaccines can put your immune function into overdrive (101) and the immune reactions become less discriminant, causing more widespread damage.

Toxins of all kinds cause oxidative stress, and this affects the power houses of the cell, which again, is called the mitochondria (102,103,104,105,106,107). This is where a diet high in antioxidants really comes in handy. Lupus situations have a higher amount of oxidative stress (108) and antioxidants like vitamin C, beta carotene, and polyphenols like resveratrol, and flavonoids like proanthocyanidins, all combat the oxidative stress and help reduce the lupus burden. (109,110) These antioxidants are all found in fruits and vegetables. (111)

Vitamin D and lupus

Then there is vitamin D. Vitamin D reduces oxidative stress, like the antioxidants. Vitamin D also reduces cell and organ damage and is essential for the proper functioning of the mitochondria. Without vitamin D, the mitochondria reduces cellular energy and limits ATP production (the fuel for cellular energy) which is needed for healing and function for just about everything including healing the lupus damage (112). Most people with lupus are vitamin D deficient. (113) The problem is that a low vitamin D level is a key player when it comes to inciting lupus and when the vitamin D is increased it becomes a major player in the remission of lupus. (114,115,116) Vitamin D equalizes the immune function allowing the overzealous attack from cytokines on the cells to calm down and it reduces inflammation. (117) Then, when you couple vitamin D with omega 3 fatty acids it becomes a powerhouse in decreasing symptoms and a major help in reversing lupus (118). All immune cells have vitamin D receptors which allow the B-cells, the T-cells and most notably the antigen presenting cells (APCs) to be more intelligent and know what to attack and what not to hurt (119,120,121). Sunlight can be the best way to get your vitamin D as well as getting the many other benefits of sunlight. For some with lupus, sunlight can be problematic, for those who have a sensitivity to sunlight, taking a good non-animal-based vitamin D3 supplement (like that sourced from lichen) can make all the difference.

Magnesium is another player on the vitamin D playing field, if you don’t have enough magnesium, you will not absorb or utilize the vitamin D you get from the sun or take as a supplement. (122) All that is being mentioned here, works together in a collaboration and that is why you see people not getting well on a particular supplement or dietary regimen. It is about the bigger picture, working to cover all the needs, like using vitamin D and omega 3s together and not forgetting to get the magnesium in from fruits and vegetables to assure the efficacy of vitamin D.

Vitamin B12 & homocysteine affect lupus

High homocysteine is a sign of inflammation and homocysteine itself can even damage the cells of the body. High blood homocysteine levels and low levels of vitamin B12 are common among those with lupus compared to those without lupus. (123) Homocysteine is especially damaging to the circulatory system especially if you are low in vitamin D. Adequate vitamin B12 can lower homocysteine (124) and thus keep levels of homocysteine in check. We need the homocysteine our body makes, just not in high amounts. It is all about keeping these things in balance. Homocysteine has been implicated in the onset of autoimmune diseases (125).  

With lupus there is a greater chance of having elevated homocysteine. (126) The higher the homocysteine levels it seems that the higher the levels of lupus activity. (127) Lupus, as was talked about earlier, comes with inflammation, and having a high homocysteine only compacts the problem (128).

With lupus there is a higher risk of heart disease (129,130) just having lupus puts a strain on the cardiovascular system (131). To lower the burden of an already high risk of heart disease, it may be best to keep the homocysteine at a healthy level. This is best done with having a healthy level of vitamin B12 (132) as well as making sure you have a good amount of the vitamin called folate (found best in green leafy vegetables) (133).

Stress and lupus

Stress holds a major factor in lupus (134). It will cause flair-ups all by itself (135). Stress alone can keep the intensity up and keep you from healing (136).  Even the disease of lupus will itself cause stress (137) Tools to reduce stress can include meditation (138) and Biofeedback (139). The need to calm down in times of stress is essential to mitigating the strength of lupus. Deep slow breathing has been shown to ease Lupus symptoms by increasing your heart rate variability which takes you from the fight or flight response of the sympathetic nervous system to the calm and relax parasympathetic nervous system. (140). Slow deep breathing helps regulate pain response in the brain as well. (140) Deep breathing can help the immune system and reduce inflammation (142). It may be most effective when practiced on a day-to-day basis and then it becomes easier to do when you are stressed out.

Summing it all up

 The fact is that lupus can be put into remission for most people, (143,144) it is not an easy task, but having lupus is not easy to start with. With all that has been covered here, it is more than just a good start, it may actually be all you need to put Lupus into remission. But you do have to do without tobacco, recreational drug use, alcohol and other damaging lifestyle habits.

Healing the gut lining is the first thing to do with a plant exclusive diet. Healing the intestinal permeability is essential to stop the constant inflow of immune aggravating proteins and chemicals into the blood stream so that the immune function can ramp down the immune overexcitability that started the whole condition in the first place. The best way to do that is by changing your diet. Feeding not only yourself but your gut microbiome (beneficial bacteria). Allowing your beneficial bacteria to thrive and create a healing environment in the digestive system.

Also, by making sure you are getting all your nutritional needs met with the needed minerals and decreasing any excesses, like heme-iron. Then make sure you are getting enough vitamin D and omega 3s fatty acids, which will put your immune function into balance, and calm the immune storm. Reducing the inflammation by keeping your homocysteine levels at a proper level by assuring you are getting enough folate and vitamin B12. As well as, making sure you are abundant in antioxidants to counter the free radicals causing oxidative stress causing inflammation and damage to your cells. If there is any question about your getting enough nutrition, there is always lab testing. Don’t guess, test. Make sure you are getting what you need to heal.

And speaking of stress, reducing the emotional strain, by using stress reduction techniques like meditation or better yet, biofeedback or just simply doing slow deep breaths, something you can do just about anywhere or anytime when needed, especially when you have been practicing stress reduction techniques each day.

Reducing the irritation of chemicals is another thing that will really help calm the storm of lupus. Your immune function has a lot of things going on and keeping the onslaught of chemicals to your bodily systems will ease the burden on the immune function and inflammation. Eat organic whole plant foods, use nonchemical/unscented soaps instead of detergents for your laundry.  Clean your house with nontoxic cleaning products and stop using air fresheners and scented items like candles, which not only puts chemicals into the air, but also, puts petroleum into the air. And don’t forget to use clean/chemical free body and hair products.

Movement is another addition, as you feel better you may be able to move some, it will help to ask the mitochondria to produce more energy, and you will progressively feel like you have more energy. The better your mitochondria works the more stable you will feel. (145) Exercise will also help you sleep better.

A good night’s sleep is known to be hard when you have lupus. With all that pain and inflammation, it can be hard to get a good night’s sleep. The proposed diet here of fruits and vegetables will help with the reduction of inflammation and irritants, and so will the avoidance of toxic substances like tobacco, alcohol, animal products, toxic chemicals, and ultra-processed foods. The addition of vitamin D, omega 3s, and the increase of antioxidants, which will also reduce the inflammation and irritation which will make it so much easier to fall and stay asleep.

This takes time to heal, so don’t expect it to turn things around overnight. Letting your body actually do the healing instead of just hiding the symptoms that is usually done these days with steroids and pain killers. For a few individuals, some of the healing may take a lot longer. For those people, there are more things that can be done, like fasting. Fasting has been proven to help people recover from lupus. (146) A word of warning here, fasting should never be done alone, you should fast under proper medical supervision.

There is more than hope, people have actually put lupus into remission. You can too. It is not easy, but it will not only rid you of the hardship of lupus, but may actually prolong your life or lifespan. Not only that, but it will give you a longer healthspan as well, to enjoy the longer life ahead of you.

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51.   Magnesium Deficiency in Systemic Lupus Erythematosus https://www.tandfonline.com/doi/abs/10.1080/13590849762691#:~:text=Reduced%20erythrocyte%20magnesium%20(Mg)%20levels,pain%20as%20a%20common%20symptom

52.   Possible roles of magnesium on the immune system https://www.nature.com/articles/1601689 

53.   Selenium and Autoimmune Diseases: A Review Article https://pubmed.ncbi.nlm.nih.gov/30324883/ 

54.   Improved survival in murine lupus as the result of selenium supplementation https://pubmed.ncbi.nlm.nih.gov/3263235/ 

55.   Selenium supplementation suppresses immunological and serological features of lupus in B6.Sle1b mice https://pubmed.ncbi.nlm.nih.gov/31006265/ 

56.   Selenium Supplementation Protects Against Lipopolysaccharide-Induced Heart Injury via Sting Pathway in Mice https://pubmed.ncbi.nlm.nih.gov/32737811/ 

57.   Mechanisms of heme iron absorption: Current questions and controversies https://pmc.ncbi.nlm.nih.gov/articles/PMC2725368/ 

58.   Elevated transferrin receptor impairs T cell metabolism and function in systemic lupus erythematosus https://pmc.ncbi.nlm.nih.gov/articles/PMC9936798/#:~:text=T%20cells%20in%20systemic%20lupus,to%20limit%20SLE%2Dassociated%20pathology 

59.   Elevated transferrin receptor impairs T cell metabolism and function in systemic lupus erythematosus https://www.science.org/doi/10.1126/sciimmunol.abq0178 

60.   Placebo-controlled randomized clinical trial of fish oil’s impact on fatigue, quality of life, and disease activity in Systemic Lupus Erythematosus https://nutritionj.biomedcentral.com/articles/10.1186/s12937-015-0068-2 

61.   Long-chain omega-3 fatty acid serum concentrations across life stages in the USA: an analysis of NHANES 2011-2012 https://pubmed.ncbi.nlm.nih.gov/33972333/ 

62.   Requisite Omega-3 HUFA Biomarker Thresholds for Preventing Murine Lupus Flaring https://www.frontiersin.org/journals/immunology/articles/10.3389/fimmu.2020.01796/full 

63.   Effect of dietary fatty acid composition on Th1/Th2 polarization in lymphocytes https://pubmed.ncbi.nlm.nih.gov/19221048/ 

64.   Heavy metals in marine fish meat and consumer health: a review https://pubmed.ncbi.nlm.nih.gov/26238481/ 

65.   Children's daily exposure to polychlorinated biphenyls from dietary supplements containing fish oils https://pubmed.ncbi.nlm.nih.gov/23281830/ 

66.   Chemicals in Fish https://oehha.ca.gov/fish/chemicals-fish 

67.   Polychlorinated biphenyls (PCBs) contamination and aryl hydrocarbon receptor (AhR) agonist activity of Omega-3 polyunsaturated fatty acid supplements: implications for daily intake of dioxins and PCBs https://pubmed.ncbi.nlm.nih.gov/20692313/ 

68.   Mercury and polychlorinated biphenyls in Asian market fish: a response to results from mercury biomonitoring in New York City https://pubmed.ncbi.nlm.nih.gov/20691969/ 

69.   Mercury Exposure and Antinuclear Antibodies among Females of Reproductive Age in the United States: NHANES https://ehp.niehs.nih.gov/doi/10.1289/ehp.1408751

70.   Environmental Factors, Toxicants and Systemic Lupus Erythematosus https://pmc.ncbi.nlm.nih.gov/articles/PMC4200809/ 

71.   Omega-3 Polyunsaturated Fatty Acid Intervention Against Established Autoimmunity in a Murine Model of Toxicant-Triggered Lupus https://pubmed.ncbi.nlm.nih.gov/33897700/ 

72.   Alpha-linolenic acid metabolism in men and women: nutritional and biological implications https://pubmed.ncbi.nlm.nih.gov/15075703/ 

73.   Efficiency of conversion of alpha-linolenic acid to long chain n-3 fatty acids in man https://pubmed.ncbi.nlm.nih.gov/11844977/ 

74.   Omega-3 supplementation can restore glutathione levels and prevent oxidative damage caused by prenatal ethanol exposure https://pubmed.ncbi.nlm.nih.gov/22841392/ 

75.   Oxidant stress, anti-oxidants and essential fatty acids in systemic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/9089797/ 

76.   A novel treatment for lupus nephritis: lignan precursor derived from flax https://pubmed.ncbi.nlm.nih.gov/10981647/

77.   Flaxseed: a potential treatment for lupus nephritis https://pubmed.ncbi.nlm.nih.gov/7564115/ 

78.   Environmental Influences on Systemic Lupus Erythematosus Expression https://pmc.ncbi.nlm.nih.gov/articles/PMC4198387/ 

79.   Cluster of systemic lupus erythematosus (SLE) associated with an oil field waste site: a cross sectional study https://ehjournal.biomedcentral.com/articles/10.1186/1476-069X-6-8 

80.   Increased liver and lupus mortalities in 24-year follow-up of the Taiwanese people highly exposed to polychlorinated biphenyls and dibenzofurans https://pubmed.ncbi.nlm.nih.gov/17257654/ 

81.   Environmental Factors, Toxicants and Systemic Lupus Erythematosus https://pmc.ncbi.nlm.nih.gov/articles/PMC4200809/ 

82.   Self-reported Lupus flare: Association with everyday home and personal product exposure https://pmc.ncbi.nlm.nih.gov/articles/PMC5598386/ 

83.   Self-reported Lupus flare: Association with everyday home and personal product exposure https://pmc.ncbi.nlm.nih.gov/articles/PMC5598386/ 

84.   Environmental Exposures and Autoimmune Diseases: Contribution of Gut Microbiome https://www.frontiersin.org/journals/immunology/articles/10.3389/fimmu.2019.03094/full 

85.   Association of exposure to nonpersistent endocrine disruptors with sex hormones and metabolic health in US females https://pubmed.ncbi.nlm.nih.gov/39440682/ 

86.   Effects of chronic exposure to DDT and TCDD on disease activity in murine systemic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/19762394/#:~:text=Taken%20together%2C%20DDT%20exposure%20appeared,was%20immunosuppressive%20to%20murine%20SLE.

87.   Mechanisms of lupus: the role of estrogens https://pubmed.ncbi.nlm.nih.gov/10410256/ 

88.   Adolescent onset of lupus results in more aggressive disease and worse outcomes: results of a nested matched case—control study within LUMINA, a multiethnic US cohort (LUMINA LVII) https://pmc.ncbi.nlm.nih.gov/articles/PMC2818044/ 

89.   The effect of menopause on disease activity in systemic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/16981295/ 

90.   Elderly-onset systemic lupus erythematosus: prevalence, clinical course and treatment https://pubmed.ncbi.nlm.nih.gov/17727302/ 

91.   Obesity and the risk of systemic lupus erythematosus among women in the Nurses' Health Studies https://pubmed.ncbi.nlm.nih.gov/28688713/ 

92.   The impact of obesity in systemic lupus erythematosus on disease parameters, quality of life, functional capacity and the risk of atherosclerosis https://pubmed.ncbi.nlm.nih.gov/22212605/ 

93.   Obesity, estrogens and adipose tissue dysfunction – implications for pulmonary arterial hypertension https://pmc.ncbi.nlm.nih.gov/articles/PMC7506791/#:~:text=Thus%2C%20as%20fat%20mass%20increases,estrogen%20production%20in%20the%20body

94.   Estrogen Receptor Signaling and Its Relationship to Cytokines in Systemic Lupus Erythematosus https://pmc.ncbi.nlm.nih.gov/articles/PMC2896666/ 

95.   The Immune System Is a Natural Target for Estrogen Action: Opposing Effects of Estrogen in Two Prototypical Autoimmune Diseases https://www.frontiersin.org/journals/immunology/articles/10.3389/fimmu.2015.00635/full 

96.   Interferon Genes Are Influenced by 17β-Estradiol in SLE https://pmc.ncbi.nlm.nih.gov/articles/PMC8558410/ 

97.   Comparison of sex hormonal and metabolic profiles between omnivores and vegetarians in pre- and post-menopausal women https://pubmed.ncbi.nlm.nih.gov/20211044/ 

98.   Vaccination and systemic lupus erythematosus: the bidirectional dilemmas https://pubmed.ncbi.nlm.nih.gov/11315360/ 

99.   Influenza and pneumococcal vaccinations of patients with systemic lupus erythematosus: current views upon safety and immunogenicity https://pubmed.ncbi.nlm.nih.gov/24044940/ 

100.     Molecular mimicry between bacterial and self antigen in a patient with systemic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/10382752/

101.     Molecular mimicry and autoimmunity https://pubmed.ncbi.nlm.nih.gov/30509385/#:~:text=Abstract,antigen%20in%20a%20susceptible%20individual

102.     Autoantibodies in Systemic Lupus Erythematosus Target Mitochondrial RNA https://pubmed.ncbi.nlm.nih.gov/31134086/

103.     The Role of Mitochondria in Systemic Lupus Erythematosus: A Glimpse of Various Pathogenetic Mechanisms https://pubmed.ncbi.nlm.nih.gov/30479205/

104.     Assessment of mitochondrial dysfunction in lymphocytes of patients with systemic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/22933065/

105.     Targeting mitochondrial dysfunction in SLE https://www.nature.com/articles/s41584-019-0332-5 

106.     VDAC oligomers form mitochondrial pores to release mtDNA fragments and promote lupus-like disease https://www.science.org/doi/abs/10.1126/science.aav4011 

107.     Targeting mitochondrial oxidative stress with MitoQ reduces NET formation and kidney disease in lupus-prone MRL-lpr mice https://lupus.bmj.com/content/7/1/e000387

108.     Lipid peroxidation is enhanced in patients with systemic lupus erythematosus and is associated with arterial and renal disease manifestations https://onlinelibrary.wiley.com/doi/abs/10.1002/art.20780 

109.     Vitamin C Supplementation in the Treatment of Autoimmune and Onco-Hematological Diseases: From Prophylaxis to Adjuvant Therapy https://www.mdpi.com/1422-0067/25/13/7284#:~:text=In%20patients%20with%20autoimmune%20diseases,inflammatory%20cytokines%20and%20free%20radicals 

110.     Significance and impact of dietary factors on systemic lupus erythematosus pathogenesis https://pmc.ncbi.nlm.nih.gov/articles/PMC6327661/ 

111.     Association of Polyphenols from Oranges and Apples with Specific Intestinal Microorganisms in Systemic Lupus Erythematosus Patients https://pmc.ncbi.nlm.nih.gov/articles/PMC4344589/ 

112.     Vitamin D Deficiency: Effects on Oxidative Stress, Epigenetics, Gene Regulation, and Aging https://pmc.ncbi.nlm.nih.gov/articles/PMC6627346/#:~:text=Vitamin%20D%20is%20one%20of,damage%2C%20and%20the%20aging%20process

113.     Vitamin D in Lupus https://pmc.ncbi.nlm.nih.gov/articles/PMC4185297/#:~:text=Until%20prospective%20trial%20results%20are,IU%20of%20vitamin%20D3%20daily 

114.     Vitamin D supplementation in systemic lupus erythematosus: relationship to disease activity, fatigue and the interferon signature gene expression https://bmcrheumatol.biomedcentral.com/articles/10.1186/s41927-021-00223-1#:~:text=Conclusions,(Trial%20ID:%20ISRCTN59058825)

115.     Metabolic alterations in vitamin D deficient systemic lupus erythematosus patients https://www.nature.com/articles/s41598-024-67588-4#:~:text=Additionally%2C%20vitamin%20D%20is%20theorized,those%20without%20vitamin%20D%20deficiency 

116.     Vitamin D in active systemic lupus erythematosus and lupus nephritis: a forgotten player https://ejim.springeropen.com/articles/10.1186/s43162-020-00016-x 

117.     Role of vitamin D deficiency in systemic lupus erythematosus incidence and aggravation https://pmc.ncbi.nlm.nih.gov/articles/PMC5743852/ 

118.     Vitamin D and marine omega 3 fatty acid supplementation and incident autoimmune disease: VITAL randomized controlled trial https://www.bmj.com/content/376/bmj-2021-066452 

119.     Vitamin D and the Immune System https://pmc.ncbi.nlm.nih.gov/articles/PMC3166406/ 

120.     Vitamin D’s Effect on Immune Function https://pmc.ncbi.nlm.nih.gov/articles/PMC7281985/ 

121.     Vitamin D and Immune Regulation: Antibacterial, Antiviral, Anti-Inflammatory https://onlinelibrary.wiley.com/doi/full/10.1002/jbm4.10405 

122.     Magnesium Supplementation in Vitamin D Deficiency https://pubmed.ncbi.nlm.nih.gov/28471760/ 

123.     Serum Homocysteine, Folate, and Vitamin B12 Levels in Patients with Systemic Lupus Erythematosus: A Meta-Analysis and Meta-Regression https://pubmed.ncbi.nlm.nih.gov/32702250/ 

124.     Efficacy of B Vitamins in Lowering Homocysteine in Older Men: Maximal Effects for Those With B12 Deficiency and Hyperhomocysteinemia https://www.ahajournals.org/doi/full/10.1161/01.STR.0000198815.07315.68 

125.     Hyperhomocysteinemia, inflammation and autoimmunity  https://pubmed.ncbi.nlm.nih.gov/17643940/ 

126.     162 homocysteine level in patients with lupus nephritis https://lupus.bmj.com/content/6/Suppl_1/A117.1

127.     Serum/plasma homocysteine levels in patients with systemic lupus erythematosus: a systematic review and meta-analysis https://pubmed.ncbi.nlm.nih.gov/32090304/ 

128.     Effect of Lowering of Homocysteine Levels on Inflammatory Markers https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486617 

129.     Cardiovascular Disease in Systemic Lupus Erythematosus: The Role of Traditional and Lupus Related Risk Factors https://pmc.ncbi.nlm.nih.gov/articles/PMC2779351/ 

130.     Incidence and risk of heart failure in systemic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/27613169/#:~:text=HF%20incidence%20was%20markedly%20higher,)%2C%20p%3C0.0001 

131.     Cardiovascular Complications in Systemic Lupus Erythematosus https://pmc.ncbi.nlm.nih.gov/articles/PMC9358056/ 

132.     Vitamin B12 and homocysteine https://pmc.ncbi.nlm.nih.gov/articles/PMC1283514/ 

133.     Vitamin B12 deficiency is the dominant nutritional cause of hyperhomocysteinemia in a folic acid-fortified population https://pubmed.ncbi.nlm.nih.gov/16197296/ 

134.     Stress and coping strategies in systemic lupus erythematosus: a review https://pubmed.ncbi.nlm.nih.gov/17709950/ 

135.     Association of Trauma and Posttraumatic Stress Disorder With Incident Systemic Lupus Erythematosus in a Longitudinal Cohort of Women https://pubmed.ncbi.nlm.nih.gov/28929625/ 

136.     The effects of daily stress and stressful life events on the clinical symptomatology of patients with lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/15385708/ 

137.     Efficacy of cognitive behavioural therapy for the treatment of chronic stress in patients with lupus erythematosus: a randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/20090397/ 

138.     Role of meditation in reducing sympathetic hyperactivity and improving quality of life in lupus nephritis patients with chronic kidney disease https://pubmed.ncbi.nlm.nih.gov/24772586/ 

139.     Effects of a stress-reduction program on psychological function, pain, and physical function of systemic lupus erythematosus patients: a randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/15334437/ 

140.     Deep Breathing Increases Heart Rate Variability in Patients With Rheumatoid Arthritis and Systemic Lupus Erythematosus https://pubmed.ncbi.nlm.nih.gov/32195851/ 

141.     The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing--an experimental study https://pubmed.ncbi.nlm.nih.gov/21939499/ 

142.     Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans https://www.pnas.org/doi/10.1073/pnas.1322174111 

143.     Six Week Raw Vegan Nutrition Protocol Rapidly Reverses Lupus Nephritis: A Case Series https://ijdrp.org/index.php/ijdrp/article/view/47 

144.     Remission of systematic lupus erythematosus https://pubmed.ncbi.nlm.nih.gov/8606630/ 

145.     Systemic lupus erythematosus and exercise https://pubmed.ncbi.nlm.nih.gov/17283578/#:~:text=Abstract.%20Systemic%20lupus%20erythematosus%20(SLE)%20is%20a,and%20fatigue%20and%20improving%20quality%20of%20life 

146.     Fasting-induced hypoleptinemia expands functional regulatory T cells in systemic lupus erythematosus https://pmc.ncbi.nlm.nih.gov/articles/PMC3288569/#:~:text=Fasting%20is%20beneficial%20in%20the,effects%20are%20not%20well%20understood