Rates of autoimmune diseases such as lupus and multiple sclerosis are on an alarming upswing, and it’s women who are most affected.
There is an epidemic going on, and women are ground zero. During the past three or four decades, rates of autoimmune disorders such as rheumatoid arthritis, lupus, Crohn’s disease, and multiple sclerosis have increased dramatically, according to a variety of reports.
Taken as a group, these autoimmune diseases—at least 100 are known—currently afflict an estimated 24 million Americans, almost twice the number of people with cancer. Even more startling than the increase is the sex difference. “Nearly 80 percent of those affected are women,” says Janine Austin Clayton, MD, director of the Office of Research on Women’s Health at the National Institutes of Health (NIH).
These chronic diseases, which can cause debilitating fatigue and enormous discomfort, are among the top 10 causes of death in U.S. women aged 65 and younger. This is a major health crisis for women, but for the most part, neither the public nor the medical establishment seems to grasp the urgency of the situation.
One reason for the public’s lack of awareness is that autoimmune disease, unlike cancer and heart disease, is not perceived as an umbrella category for a single family of linked conditions.
Diagnosis and treatment are provided by disparate specialties such as neurology, rheumatology and endocrinology, and “because the fields are so different, communication among the doctors and researchers is often not optimal,” says Noel R. Rose, MD, PhD, director of the Johns Hopkins Center for Autoimmune Disease Research.
Yet the underlying biology of various autoimmune diseases is similar. If a person has one autoimmune disease, it is “very common” for her to acquire another type later in life, says Frederick R. Miller, MD, PhD, chief of the Environmental Autoimmunity Group at the National Institute of Environmental Health Sciences (NIEHS).
Blood relatives may suffer from different kinds of autoimmune diseases, suggesting there is a propensity to inherit a general flaw in the immune system regardless of which organ becomes affected.
While many parts of the puzzle are not yet in place, here’s how scientists explain the huge jump in cases of autoimmune diseases—and how you can use the information to protect yourself from developing one.
Why Women Are Vulnerable
Autoimmune diseases develop when your immune system mistakenly identifies normal parts of the body as intruders and produces what’s known as autoantibodies to attack them. Auto-antibodies, along with other types of immune cells, can create chronic—and damaging—inflammation in healthy cells, tissues and organs.
Women are better than men at fending off infections because our immune systems are cranked up higher. That’s a good thing if you’re exposed to a flu virus but not so great if you’re susceptible to autoimmune diseases.
Experts believe that the different effects of sex hormones may partly explain why the distaff side is much more prone to autoimmune diseases. “There are many experiments showing that estrogen makes the immune system more likely to attack the person it’s living in, while testosterone actually prevents the immune system from making these mistakes,” says Philippa Marrack, PhD, a senior faculty member at National Jewish Health in Denver.
Another reason women more often develop autoimmune diseases is that they have an extra X chromosome.
Conventional medical thinking has been that one version of a female’s X chromosome is turned off, or silenced, by complicated genetic mechanisms before birth to forestall the production of excess genetic material. “But it appears that the second X chromosome is not completely turned off. It sort of flickers,” says Marrack.
The genes on the extra X chromosome help create what Marrack and her colleagues have termed ABCs: age-associated B cells. Normal B cells are immune system components that produce pathogen-attacking antibodies, but ABCs appear to stimulate the development of autoantibodies. “We spotted ABCs in elderly female mice and in women who had an autoimmune disease, but not in men,” says Marrack.
In her team’s research, these cells increased in number as healthy female mice aged, but they consistently remained at low levels in healthy male mice.
The number of ABC cells also grew as women with rheumatoid arthritis became older. Marrack’s conclusion: “Flickering of women’s supposedly inactive X chromosome and the ABCs that are created may be one of the reasons women get autoimmune diseases more than men.”
How Our Environment Fuels the Epidemic
The tendency to develop autoimmune diseases is inherited, but the fact that you carry certain genes doesn’t necessarily mean you’ll be affected. Rather, the scientific consensus is that these disorders arise from an interaction of genes and environmental triggers. “Genes probably account for one third of the risk, but something in the environment accounts for the rest,” notes Rose of Johns Hopkins.
In fact, most experts believe that the recent jump in autoimmune cases happened too quickly to stem from genetic changes, so other contributors must be at work. “Food, air, water and our activities are different from what they were in our grandparents’ day,” says the NIEHS’s Miller. “For instance, every year thousands of new chemical compounds are registered for industrial use, but we don’t know their effects.”
A couple of years ago, an expert panel convened by the NIEHS pored over the available studies assessing environmental factors and autoimmune diseases.
In a 2012 report in the Journal of Autoimmunity, Miller and his associates found likely or convincing evidence of a number of links: Past smoking is connected with one form of rheumatoid arthritis, current smoking with lupus, MS, Crohn’s disease and thyroid disease; exposure to the Epstein-Barr virus with MS; and use of solvents (for instance, dry–cleaning chemicals and paint thinner) with MS and systemic scleroderma (a connective tissue disease). “These environmental factors can turn genes on or off via certain chemical changes,” explains Monica Mallampalli, PhD, director of scientific programs at the Society for Women’s Health Research.
How to protect yourself: Reduce your exposure to environmental triggers by not smoking and by staying away from any chemical that “you can smell, makes you cough or sneeze or irritates your eyes,” says Miller.
The Problem with Salt
For years doctors have urged us to limit the amount of salt we consume because excess sodium increases the risk of heart attack, stroke, osteoporosis and kidney disease. Now there’s another reason: High-salt diets may bear part of the blame for the rising rate of autoimmune disease.
Immunobiologist David Hafler, MD, chair of the department of neurology at Yale University, became interested in the role of salt when he noticed that patients who frequently ate fast food showed increased production of a specific type of immune cell linked to autoimmune diseases. Called a TH17 cell, it produces an inflammatory protein.
In a paper that appeared last year in the journal Nature, Hafler and his team found that diets high in salt increased levels of these cells in both lab tissue culture and mice genetically engineered to develop a form of MS.
Hafler cautions, “We haven’t yet shown that salt is an independent risk factor for autoimmune disorders, simply that there’s a link between a high-salt diet and MS in mice genetically predisposed to the disorder.” Studies to test for the same effect in humans are underway. But Hafler isn’t waiting for the results of those studies; he recommends a low-salt diet to his patients with autoimmune diseases.
How to protect yourself: Since processed foods and fast food can contain more than 100 times the salt in meals cooked at home, Hafler suggests avoiding these foods as much as possible.
The “D” Defense
We’re often warned against going outdoors in sunlight because it promotes skin cancer, but there is an upside: Exposure to UV radiation seems to protect against some autoimmune diseases, especially MS and possibly also type 1 diabetes (sometimes called juvenile diabetes).
The closer to the equator you live, the less likely you are to develop an autoimmune disease; these dis-orders are considerably less common among those who dwell in the southern U.S. than among residents of Canada and the northern U.S. Where you spent your early years is also important. If you lived in the South for your first 10 years, you have a reduced risk of developing MS even if you move to Ontario and stay the rest of your life.
Vitamin D may well be the crucial variable. During sun exposure, ultraviolet B rays trigger the production of this vitamin in the skin, which helps modulate your body’s defense system. “If you have the potential for developing autoimmunity, vitamin D dampens that to reduce the risk,” says Michael Holick, PhD, MD, professor of medicine, physiology and biophysics at Boston University. Epidemiological studies have suggested that in women, high intake of vitamin D is associated with a 40 percent reduced risk of developing multiple sclerosis and rheumatoid arthritis. 
But since people are cutting back on sun exposure to avoid skin cancer, they may fall short on vitamin D, which is difficult to obtain from food alone. At least one study indicates that vitamin D supplements may change the course of an autoimmune disorder; in January researchers at Harvard reported that vitamin D supplements may slow the progression of early-stage multiple sclerosis.
How to protect yourself: If you have an autoimmune disease or a family history of one, consider taking vitamin D supplements. But you should know that scientists have yet to determine how much is needed. Currently, 2,000 to 4,000 IU of vitamin D daily is regarded as safe. Holick recommends 3,000 IU daily, which is what his family takes. “It doesn’t matter whether you live in Florida or Alaska or whether you regularly play tennis or golf outdoors; 3,000 IU of vitamin D a day will maintain your blood level and will not cause toxicity,” he says.
The Good News About Treatments
Although research on preventing autoimmune diseases is in its infancy, in the past few decades great strides have been made in managing (though not curing) these conditions.
The side effects of older treatments like corticosteroids that suppress the entire immune system are often harsh; they can cause high blood pressure, weight gain and osteoporosis.
But newer medications, such as Enbrel for rheumatoid arthritis and Benlysta for lupus, target specific components of the immune system and provide greater benefits (such as reduced pain) with less damage to the body, notes Michael Lockshin, MD, director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York City.
Early diagnosis is crucial, however. “In most autoimmune diseases, there’s inflammation of the tissue in, say, the kidney, heart or brain,” says Rose. These tissues often become fibrotic, a process akin to scarring that can ultimately interfere with the functioning of an organ. “If we can treat an autoimmune disease in its earlier inflammatory stage—and we now have more anti-inflammatory drugs available—then it may be possible to at least arrest the disease so it won’t proceed any further,” he says.
The catch: Diagnosis is difficult. The first symptoms of an autoimmune disease are distressingly vague—-unremitting fatigue, muscle aches and difficulty concentrating.
On average, patients report that it takes more than three and a half years and nearly five doctors for them to receive a correct diagnosis, according to a survey by the American Autoimmune and Related Diseases Association (AARDA). Even if patients are tested, the results can be ambiguous. “It’s pretty easy to know that a specific disease is not present,” says Lockshin.
But tests can indicate the presence of diseases in up to 15 percent of people who don’t have them. That’s one reason researchers are looking hard for biomarkers, such as specific antibodies, that can provide an early and accurate diagnosis of an autoimmune disease.
How to protect yourself: If you suspect an autoimmune disease, tell your internist or family doctor that you want a consultation with a physician who specializes in these disorders, Lockshin urges.
Seven out of 10 family physicians say they believe they didn’t receive adequate training in diagnosing and treating autoimmune diseases, the AARDA finds.
Lockshin emphasizes the importance of persevering: “Don’t be put off by doctors who attribute everything to emotions or tell you it’s all in your head and here’s an antidepressant.
Doctors find it easy to say, ‘If I don’t see it, it doesn’t exist.’ ” But autoimmune diseases are real, they are manageable—and they are increasing.
The Bottom Line
Autoimmune diseases receive nowhere near the funding that other major illnesses do. For the fiscal year 2023 at the NIH, for instance, research money going to cancer totals an estimated $5.4 billion; to heart disease, $1.3 billion; and to autoimmune diseases, $838 million. “These are critical diseases for us to focus on as a society, and most Americans don’t realize how much bigger a role they are going to play in our future,” says Miller of the NIEHS. Preventing and curing these debilitating and potentially fatal illnesses, he says, “will take money and dedicated effort.”
This story first appeared on More.com by Nissa Simon.
- Lindor, Keith D. “Management of Osteopenia of Liver Disease with Special Emphasis on Primary Biliary Cirrhosis.” Seminars in Liver Disease, 1993, https://doi.org/10.1055/s-2007-1007365. ↩︎
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