Tackling mixed connective tissue disease with nutrition

Photo Cred: Daria Shevtsova/Pexels

By Kellie Blake, RDN, LD, IFNCP, Kellie Blake, RDN, LD, IFNCP

Like many autoimmune diseases, mixed connective tissue disease (MCTD) is not well-understood and symptoms often overlap with other disorders, making it difficult to differentiate. Patients experience symptoms including Raynaud’s syndrome, joint inflammation, swollen hands, muscle weakness and soreness, difficulty breathing, fatigue with exertion, swallowing difficulty, heartburn, lupus-type rashes, interstitial lung disease, pulmonary hypertension, heart failure, and Sjogren syndrome.

My patient experienced many of these symptoms and had received the diagnosis of undifferentiated mixed connective tissue disease, meaning symptoms are present, but not yet specific enough to make a formal diagnosis.

I admit, I was a bit perplexed when my patient didn’t seem engaged with my initial recommendations.  We had such a great first appointment and I was extremely hopeful, but after that meeting, she didn’t seem interested in following up. I worried that I had overwhelmed her and was afraid she may not be able to implement the strategies we discussed. It wasn’t until months later, at our first follow-up, that I realized the reason for her hesitance. 

My patient understood and could implement the recommendations, but she was afraid. She said she couldn’t fully engage initially out of fear of failure. She viewed nutrition therapy as her last resort, and if it failed, that would be too much to bear as she had already struggled significantly. My patient said her illness had caused her to lose herself and she desperately wanted to return to her previous quality of life but feared this would never happen. 

While there are many areas of focus in the treatment of MCTD, I find targeting gut and mitochondrial function to be very beneficial for symptom improvement. There is no current research connecting dysbiosis to undifferentiated or mixed connective tissue disease, but this evidence does exist for other connective tissue diseases, such as lupus and Sjogren’s syndrome. All connective tissue diseases are characterized by anatomical and physiological changes to the mucosa and skin that predispose patients to dysbiosis. Dysbiosis leads to an increase in inflammatory pathways and is known to be a trigger for many autoimmune diseases even though this process in MCTD has not yet been elucidated through randomized controlled trial. I believe this mechanism of altered gut function is still a valid target for nutrition therapy.

Mitochondrial function is another focus for those with MCTD. The mitochondria use food and oxygen to create energy, maintain optimal cell function, and prevent premature cell aging. Optimizing mitochondrial function can possibly decrease the fatigue, pain, and brain fog associated with MCTD. A meal plan rich in polyphenols will promote mitochondrial biogenesis and healthy mitophagy and is a great option for these patients. A high-fat, high-glucose diet is known to inhibit mitochondrial biogenesis and lead to mitochondrial dysfunction and altered mitophagy. This dysregulation is seen in aging, but also metabolic and neurodegenerative diseases and cancer. 

Case Study

My patient is a 52-year-old female with a diagnosis of undifferentiated mixed connective tissue disorder, Epstein-Barr virus (EBV), and chronic fatigue. She was also struggling with metabolic syndrome and pre-diabetes. Several years prior, this patient had lived in Africa and Asia, where she contracted malaria and dengue fever three times, as well as hepatitis A. She had multiple episodes of intestinal parasites including giardia, amoeba, and whip worms.

The patient experienced an intense psychological trauma when she contracted bacterial pneumonia. This led to a recurrence of her EBV and autoimmune issues. She had a significant history of antibiotic use as a child. She was unable to exercise due to extreme fatigue and muscle weakness, she felt extreme stress, and her sleep was disrupted. She went from living a very healthy and active life to feeling sick and tired daily, with community and social engagement.

She was taking medications and supplements including duloxetine, gabapentin, buspirone, loratadine, cinnamon, multivitamin, krill oil, calcium, vitamin D3, and magnesium. Her meal plan already excluded dairy, legumes, grains, soy, added sugar, eggs, and artificial additives, but she reported she wasn’t as strict as she felt she should be.

Based on her history, I knew my patient was experiencing significant gut dysfunction. She was already eliminating many foods from her diet, so instead of an elimination diet, I targeted gut and mitochondrial function. Her meal plan focused on nutrient-dense plant-based foods and is anti-inflammatory, gluten-free, low-glycemic, low in grains, and high in good quality fat. In addition to the food plan, my initial plan for her included:

1. Home stomach acid testing
2. Supplements, including CoQ10, 200 milligrams per day in divided dose; vitamin B complex every morning; magnesium glycinate, 200 to 400 milligrams every evening before bed; acetyl-l-carnitine; a multivitamin; and formulas for pain, inflammation, and musculoskeletal symptoms.
3. Testing, including salivary cortisol testing, comprehensive stool analysis, red blood cell magnesium, methylmalonic acid, a celiac panel, and homocysteine.
4. Recalibrate circadian rhythm with sleep hygiene, no sunglasses, and early morning natural light exposure.
5. Stress management, including meditation for at least 10 minutes per day with a goal of 20 minutes twice per day and regular massage therapy.
6. Movement to include relaxation yoga and walking for 10 minutes after meals as able.

When we followed up after seven months of nutrition therapy, the change was physically noticeable. She was smiling and seemed much more relaxed. She described herself as more resilient emotionally and had lost 12 pounds.

Her symptom score is down from 209 initially to 160 and she reports following a strict meal plan. She modified her initial meal plan to eliminate legumes and starchy vegetables, which she feels has significantly improved her symptoms.  

She completed the nutritional supplements recommended for the adrenal dysfunction and maintains a supplement regimen to include magnesium, calcium, multivitamin, and krill oil. Her gastrointestinal function has significantly improved, and she reports at least one normal bowel movement every day.

Her physical activity is improving, and she is participating in chair yoga twice per week, as well as other light activities.

The recommended follow-up goals included:

1. Decrease magnesium supplement to 200 milligrams per day, since her meal plan is providing an excellent amount of magnesium.
2. Focus on increasing variety in vegetables and aim for nine to 10 servings of vegetables every day to feed the gut microbiome.
3. Add a fermented food daily to feed the gut microbiome.
4. Consider a green smoothie for breakfast a few days per week and move usual breakfast to snack time to help maximize vegetable intake.
5. Decrease to only one square of dark chocolate per day due to having hot flashes with consumption.
6. Consider adding Qigong.

My patient has regained her quality of life with a tailored nutrition protocol. The addition of a targeted meal plan, nutritional supplements, and lifestyle modification by recalibrating the circadian rhythm and focusing on stress management were important additions for symptom reversal.

References

Nevares, M. (2018). Mixed Connective Tissue Disease. Merck Manual Consumer Version. Retrieved from https://www.merckmanuals.com/home/bone,-joint,-and-muscle-disorders/autoimmune-disorders-of-connective-tissue/mixed-connective-tissue-disease-mctd

Popov, L. (2020). Mitochondrial biogenesis: An update. Journal of Cellular and Molecular Medicine. Retrieved from: https://onlinelibrary.wiley.com/doi/full/10.1111/jcmm.15194

Talotta, R., Atzeni, F., Ditto, M., Gerardi, M., & Sarzi-Puttini, P. (2017). The Microbiome in Connective Tissue Diseases and Vasculitides:  An Updated Narrative Review.  Journal of Immunology Research. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556609/