Nutrition & Diet Overview:
Multiple Sclerosis (MS) is a complex disease and one of the things we need to think about in addition to how diet affects our MS and symptoms is also how we need to avoid falling into other diseases such as hypertension, obesity or diabetes for example. Diet and nutrition play a significant role in all of these matters respective. The last thing we need with MS is hypertension, diabetes or other disorders. MS is quite enough!
Diet can help us avoid risk factors that we can engage where-as perhaps hereditary factors cannot.
While studies have taken place in respect to some dietary factors with multiple sclerosis there is no definitive evidence that diet will modify the course of the disease. Large scale studies of nutrition and MS are difficult to perform because the individual subjects are completely different people. They have different habits, different matters of compliance, different physiology, genetics, age to name just a few aspects.
All that said and done many people who endure MS do often feel better by undergoing dietary changes just as is the case in healthy people who change to a healthy dietary regimen. What is in question is whether dietary aspects of life can affect multiple sclerosis symptoms or disease activity directly. Some say yes, some say no. What is known is no matter if a person is healthy or not a healthy diet for most people will result in a better more functional quality of life and there are studies that do show this outside of MS.
The Gut Microbiota:
Gut flora, gut microbiota, or gastrointestinal microbiota is the complex community of microorganisms that live in the digestive tracts of animals. The gut microbiota has the largest numbers of bacteria. This microbiome also contains the greatest number of species compared to other areas of the body. An associated term, sometimes used interchangeably with gut microbiota, is gut microbiome, which refers to the aggregate of all the genomes of gut microbiota.
Gut microorganisms benefit the host by collecting the energy from the fermentation of undigested carbohydrates (sugars, starches and fibers found in fruits, grains, vegetables and milk products) and the subsequent absorption of short-chain fatty acids formed during bacterial fermentation of carbohydrates in the colon.
Without going into a scientific dissertation on the subject there are many many types of these microorganisms and literally billions of them in our guts both good and bad. They perform all types of varying functions such as synthesizing vitamin B and K, acids, sterols and more. The complex interactions as well as service impacts to other organs is ever so complex. A great deal of research is underway and in fact many researchers consider the gut microbiome to be another organ in its own right and deem it “the forgotten organ”.
It is estimated that the gut flora has around a hundred times as many genes as there are in the human genome, the humane genome has over 3 billion pairs.
What is being found is the gut microbiome has linkage to many aspects of our body and it is appearing that linkage also exists to many suspect diseases. Some researchers believe that gut microbiome has some linkage to MS and research continues.
How Diet Might Affect MS:
Direct effects on the immune system: Recent immunological research has shown that metabolism plays an important role in the function of several types of immune cells. Additionally several immune cells have receptors (surface structures that allow cells to connect and communicate with other cells) for various types of dietary metabolites (vitamin D, fatty acids). Thus intake of certain types of fats has been linked to greater inflammation while intake of polyunsaturated fatty acids (PUFAs) has the opposite effect.
Indirect effects through modulation of the gut flora: The gut bacteria metabolize certain components of the diet into short chain fatty acids that, besides helping in colonic health, can also act on immune cells and make T cells more regulatory. Additionally diet can lead to alterations in the gut bacterial composition that can shift the immune system towards a pro- or antiinflammatory state.
Effects on components of the central nervous system: As mentioned above, since altered metabolism may play a role in the adaptation of the nervous system to damage, various experimental foods and diets are being studied for their effects on the various cellular components of the central nervous system such as the neurons and other glial cells. Diets could have a beneficial role by providing factors that could be protective of these cell populations.
Multiple Sclerosis Diets:
Over the years several diets have emerged that many people who endure multiple sclerosis have engaged in. Some patients claim very significant gains through dietary change often accompanied by exercise and some patients not so much. Since MS really affects each person differently and each person by very nature is different changes in lifestyle will surely result in varied results which as stated above is why clinical studies are so difficult to get quantifiable data from in respect to diet and MS.
You may have heard of some of the diets such as The Swank Diet or Paleo Diet for example. There are several diets which people who endure multiple sclerosis have tried.
Below is a brief synopsis of each of these diets:
Paleolithic Diet (Paleo Diet):
The Paleolithic diet is based on the hypothesis that our bodies are poorly evolved to handle the modern diet that emerged primarily following the agricultural revolution. It advocates a switch to foods that would have been consumed by our ancestors in a hunter-gatherer lifestyle.
The paleo diet is also a component of the Wahls protocol that has been popularized by Dr. Terry Wahls.
Guidelines for the Paleolithic diet:
The Paleo diet provides guidelines for the kinds of foods that should be eaten and the balance in sources of caloric intake. The first step is to eat natural foods while avoiding highly processed food, especially high glycemicload foods (carbohydrate foods that significantly raise blood sugar). The Paleo diet also emphasizes the intake of game (nondomesticated) meats and plant based foods besides cereals (fruits, roots, legumes and nuts). Animal protein is recommended to be the source of about 30-35% of the daily caloric intake. Consumption of lean game meats also helps in reaching the recommended level of PUFA intake.
In the Paleo diet the ratio of saturated fats to PUFA is between 1.4-2:1 – unlike the modern diet in which the ratio is closer to 10:1. The Paleo diet is also high in fiber (45-100 g/day) that is derived from plant sources that are not cereal based. While some sources advocate avoiding potatoes and legumes, others do not. This could be secondary to the fact that potatoes have a high glycemic index.
Modified guidelines for the Paleo diet taken from a study that is quoted below include the following recommendations:
1. Consume 3 servings each/ day of green leafy vegetables, sulfur rich vegetables and intensely colored fruits or vegetables.
2. Consume 2 tablespoons of omega-3 oils; 4 oz. or more each of animal protein and plant protein; only non-lactose containing milks; no more than 2 servings per week of gluten-free grains/ starchy foods.
3. Do not consume any dairy, eggs or gluten containing grains.
Evidence in MS or other autoimmune disease:
A small uncontrolled, single-arm study looked at the effect of a multimodal intervention that included a modified Paleo diet on people with secondary progressive MS. In this study there was significant improvement in fatigue scores over a period of 12 months.
This study, however, also involved exercise, stretching, massage, meditation and electrical stimulation, and did not include a control group on a reference (comparison) diet. There is a need for larger controlled trials of the Paleo diet in people with MS.
Evidence in non-autoimmune disorders:
A recent study randomizing people to the Paleo diet or a reference diet showed improvements in several cardiovascular risk factors; however, the Paleo diet group also had a reduction in body weight and a portion of the beneficial effect could have been derived from the weight loss.
Possible deficiencies that may result from the diet:
The Paleo diet can result in deficiencies in folic acid, thiamine and vitamin B6 (due to reduced intake of cereals), calcium and vitamin D (due to lack of dairy intake) and insufficient caloric intake without appropriate nutritional advice.
The Swank Diet:
The Swank diet was described by Dr. Roy Swank and was used by him to treat patients with MS for several years. The diet is essentially a low fat diet that focuses on reducing both saturated and unsaturated fats.
Guidelines for the Swank Diet:
Saturated fat intake should not exceed 15 grams/day, while unsaturated fat /oils intake should be kept below 20-50 grams/day. No processed foods containing saturated fats should be consumed. Similarly dairy products must contain less than 1% fat. Whole grain cereals and pastas are recommended. Two cups each of fruits and vegetables are recommended. No red meat intake is allowed for the first year after which 3 oz. of red meat are allowed weekly. White fish and shellfish are permissible in any amount. Skinned trimmed poultry meat is permissible. A cod liver oil and multivitamin supplement is also recommended.
Evidence in MS Dr. Swank in 1970 reported the effects of his diet over a period of 20 years on patients with MS. In this observational report, he suggested that the diet reduced occurrence of relapses, accumulation of disability and mortality.
It is important to note that the study did not have a control arm to compare the subjects on the diet. Also a standardized scoring system such as the EDSS was not available at that time, making comparison with other groups of MS patients challenging.
Evidence in non-autoimmune disorders:
No evidence for the Swank diet exists in non-autoimmune disorders.
Nutritional deficiencies that may develop due to this diet:
Though no definite deficiencies would be expected to develop from this diet, a recent study showed that those following this diet were consuming less than the recommended levels of vitamin A, C, E and folate.
Gluten Free Diet (GFD):
A GFD is a diet completely devoid of products derived from gluten containing cereals – wheat, barley, rye and triticales (a cross between wheat and rye). Gluten is a protein that is composed of gliadin and glutenin that are found conjoined with starch in wheat, rye and barley. It is a major component of the proteins found in wheat. Gluten sensitivity is a feature of celiac disease and GFD is a common treatment for this disorder. Besides celiac disease, gluten sensitivity has also been noted in a condition called non-celiac gluten sensitivity (NCGS), which can also lead to gastrointestinal symptoms.
Guidelines for a GFD:
It is important to remember that “wheat-free” is not the same as “gluten free”. For a GFD it is necessary to avoid all food containing any derivatives of wheat, barley or triticales. Additionally it is also important to consider cross-contamination if the food is prepared in an area where these products are utilized. It is also important to find substitutes since this helps in ensuring that the avoidance of gluten containing foods does not result in significant restrictions in caloric intake and ultimately in nutritional deficiencies.
Evidence for a role in MS:
There is no evidence for a role of GFD in patients with MS. Multiple studies suggest that people with MS have the same prevalence of anti-gliadin and anti-TTG antibodies (antibodies elevated in Celiac disease) as healthy controls. GFD is a treatment for celiac disease and dermatitis herpetiformis (a chronic, itchy, bumpy and red rash). It has also been evaluated in other autoimmune conditions such as rheumatoid arthritis with no definite role for GFD noted in these disorders.
Evidence for a role in non-autoimmune disorders:
There is no evidence for a role for GFD in non-autoimmune disorders.
Nutritional Deficiencies that may result from this diet:
No definite nutritional deficiencies expected if gluten-free breads and cereals are substituted.
The McDougall diet is a low-fat, high carbohydrate, moderate sodium, vegan diet. It is based on the premise that the rich Western diet is the cause of several chronic diseases. It aims at eliminating animal based food and vegetable fats and replacing them with low-fat plant based foods.
Guidelines for the McDougall diet:
The basic components are plant sources of complex carbohydrates and starch (refined flour or white rice are excluded). The suggested staples of the diet include wheat flour products, corn, rice, oats, barley, quinoa, potatoes, sweet potatoes, beans, peas, and lentils. Fresh fruits and non-starch green or colored vegetables can be added to the diet in any quantity. A low sodium intake is encouraged and small amounts of sugar and spices may be used to flavor foods. No animal-derived foods are allowed; therefore dairy, eggs, meat, poultry and fish are excluded. In addition, oils are not allowed (including vegetable oils).
Evidence in MS or autoimmune disease:
No evidence exists in MS or other autoimmune diseases.
Evidence in other disorders:
A study from the McDougall center showed that 7 days of the diet led to a reduction in weight, BP and cholesterol levels. This study did not comment on the long-term effects of the diet.
Nutritional deficiencies that may result from this diet:
The McDougall diet could result in deficiencies in iron, vitamin B12, vitamin D, calcium and Omega 3 fatty acids.
Mediterranean Diet (MD):
The Mediterranean Diet is one of the most extensively studied diets in the setting of cardiovascular health. It has several similarities to the Paleolithic diet but in some ways is more practical to follow. The MD has many components which are thought to be beneficial, however most research suggests the Mediterranean Diet as a whole has far greater benefit than its individual components.
Guidelines for Mediterranean Diet:
There are various definitions of the Mediterranean Diet, however they generally share the following components: high intake of whole grains, vegetables, fruits, legumes, olive oil and fish; a low intake of saturated fats (butter and other animal fats), red meat, poultry, dairy products; and a regular but moderate intake of ethanol mainly consisting of red wine during meals. The Mediterranean Diet is part of the Mediterranean lifestyle.
Evidence for a role in MS or other autoimmune disorders:
There are currently no data for a role of the Mediterranean Diet in MS. A meta-analysis of 17 randomized controlled trials demonstrated a benefit of the Mediterranean Diet on markers of inflammation.
Evidence for a role in non-autoimmune disorders:
There is evidence for a beneficial effect of the Mediterranean Diet in type 2 diabetes, cardiovascular disease prevention and perhaps even in cancer prevention.
Nutritional deficiencies that may result from following this diet:
No specific nutritional deficiencies would be expected from following the Mediterranean Diet.
The Wahl’s Protocol:
The Wahl’s protocol is based on a Paleo type diet. Dr. Terry Wahl’s has used herself as an initial subject, eliminating gluten, legumes, and dairy products. There is a small amount of certain legumes allowed in the protocol on a weekly basis. All foods must be organic, including meats and seafood.
Gold Coast Cure:
The Gold Coast Cure (Larson & Larson, 2005, Deerfield Beach, FL: Health Communications, Inc.), written by a woman living with MS, Ivy Larson, and her physician-husband, Andy Larson, this plan focuses on the importance of nutrition and exercise in improving the general health of one living with MS, and now, for inflammatory conditions in general.
Some consider it a “modified-Swank” protocol. You can eat a daily “sweet treat” on this program as it is “all natural.” It may contain refined flour or sugar, though nothing else during the day may contain these ingredients. It may not contain hydrogenated or partially hydrogenated oil, margarine, or vegetable shortening. You may use condiments in small quantities, and you may use Splenda or Stevia. I prefer Stevia, as it is a more natural sugar substitute.
- Eliminate trans fats.
- Eat more whole carbohydrates: whole wheat breads and pastas, brown rice, oatmeal, beans, fruits, vegetables
- Limit saturated fat intake to 15 grams per day if you have an inflammatory condition
- Eat anti-inflammatory essential fats, with an appropriate balance of omega-6 (sources such as soybeans, whole grains, nuts) to omega-3 (sources such as fish, shellfish, walnuts, flaxseed and oil, canola oil)
- Switch from using mass-market vegetable oils to “properly prepared, unheated omega-3 oils”
- Eat fiber in high quantities, their rule is 2-3g fiber / 25g carb
- Eat a wide variety of whole foods to obtain optimal amounts of micronutrients
Most neurologists, researchers and clinicians agree that dietary and exercise aspects of management of multiple sclerosis is important however that none are a cure for the disease. Thus patients engaging in a dietary regimen are advised by their healthcare teams to continue receiving disease oriented treatment therapies.
It is important before considering any sort of significant change such as dietary lifestyle to completely engage your healthcare team. Do not simply decided to try dietary changes, supplementation changes or other significant changes without consulting your healthcare team. This means your COMPLETE care team. For example it would be rather unwise for a MS patient who also has cardiology, diabetes or is geriatric for example to not consult ALL members of their healthcare team. So, all physicians clinical and/or mental wellness before engaging in changes such as dietary or supplementation.
You may want ask your care team if they can refer you to a dietician to help guide you towards a dietary protocol. It is a wise move with multiple sclerosis to do this so your nutritional needs and life aspects can be reviewed to put you on a proper entry path towards dietary changes. The same is true of exercise and physical or occupational therapy. Consult your COMPLETE care team and then move forward.
Guessing with any disease is just rather unwise. Guessing with neurological diseases is just very unwise.
Do not be surprised if a dietician or your healthcare team recommends beginning dietary change towards a diet such as that recommended by the US Department of Agriculture (USDA) or the Heart Association forms of diets. These diets tend to be highly vetted towards complete nutrition and not lacking in areas. Then a dietician can work with you to help tweak and maximize food intake towards the various aspects of your life and lifestyle.
Some special diets may be harmful because they include potentially toxic amounts of certain vitamins, or exclude important nutrients. That’s why it’s important to consult with your healthcare professional before starting any diet that includes nutritional supplements or vitamins. — US National Multiple Sclerosis Society
A Note On Supplementation:
Supplements are available in all varieties of forms from vitamins to essential fatty acids and a whole lot between. As with dietary change any supplementation should be thoroughly discussed with your COMPLETE healthcare team.
Many many people with chronic diseases such as multiple sclerosis look towards the internet and what people say they do towards management of their MS. Just because supplements are sold over the counter does not by any means they are safe for you to consume given your physiology, medical condition(s), lifestyle or other aspects of your life. For example, many people engage in taking curcumin which some past studies suggested had an impact on MS progression. Long term usage of curcumin may however result in ulcers or other issues. Tumeric is another supplement some people take towards MS. Long term usage however can result in exacerbating bile duct obstruction. Some 50% of American’s it is estimated already have some level of obstruction. Bile-duct obstruction may be dealt with via breaking up the obstruction. Some cases require surgery and yet others result in polyps and even bile duct cancer.
Point being just as prescription or nonprescription medications all have side effects so may supplements and so does food.
Most of us know that if we eat too many sweets for many years we stand a larger risk of diabetes. We know if we eat greasy foods all the time our risks towards cardiovascular disease rise significantly.
A 24 year old woman’s dietary requirements may well be quite different from a 24 year old males or a 58 year old womans or a geriatric 76 year old women. They in fact ARE.
Taking supplements, dealing with dietary requirements is thus recommended be done with the help of a dietician and your healthcare team. Thus real measurements can be monitored that can best be applied to your present life condition.
As a side note to all of this, once you do reach geriatric age regardless of medical conditions its VERY important to engage a geriatric physician .vs. a general practitioner. The specialization that comes with aging is real and important to not ignore. Matters such as neurological conditions and more are often better understood by geriatric physicians than general practitioners as they are more common in their practice and they have received some levels of specialized education and of course a much higher degree of education towards aging in general.
While many different dietary strategies are being promoted for people with MS, currently there is insufficient evidence to recommend any of these strategies. Interestingly despite the differences between these diets there are several common themes. Almost all the diets advocate avoiding highly processed food, foods with high glycemic index and food that is high in saturated fat. Most diets also recommend reducing consumption of fatty red meat and increasing consumption of fruits and vegetables. Other approaches to diet are also being considered and include caloric restriction, which appears to be effective in animal models of MS. Trials of caloric restriction in people with MS are now underway. More systematic evaluation of dietary strategies in MS is required. However, while we wait for such research to be done, following a diet that incorporates some of the themes that are common to these various diets and also has beneficial effects for overall health may be the most pragmatic option at this time.