Intermittent Fasting And MS, The Devil Is In The Details

I read an interesting article on NPR.org yesterday. The article was written by a participant in the Johns Hopkins pilot study that is looking at the impact of intermittent calorie restriction on the microbiome and symptoms in people with MS. The microbiome of MSers, it turns out, are different than non-MSers but the details of how they differ and why are currently unknown. Which means that all of the stuff currently marketed online to fix or heal your gut is, at this point anyway, not based on anything scientific. I hope this research helps to put this really complicated puzzle together.

 

Some background on the Johns Hopkins Study

Intermittent fasting has resulted in less severe disease in mice with EAE (the mouse version of MS) and the Johns Hopkins study is investigating the safety and impact of intermittent fasting on humans. 36 participants will be assigned to one of 3 diets for 6 months:

1. Continuous caloric restriction

2. Intermittent caloric restriction

3. A placebo control diet providing enough calories to maintain current weight

The main objective of this pilot study is to make sure the nutrition intervention is safe and does not result in adverse outcomes. If caloric restriction proves to be a safe intervention, it may lead to additional studies.

Additionally, this controlled intervention study will measure adherence (aka compliance) to the intervention. It will include self-reported subjective data (fatigue and quality of life questionnaires) as well as take a look under the hood so to speak to see if there are any objective measurable clinical changes (immune cytokines, oxidative stress biomarkers, serum lipids, fasting glucose, insulin, leptin, ghrelin, c-reactive protein, etc).

 

Back to the NPR article.

What I LOVE and appreciate about the NPR article is that it provides the human perspective that is usually missing in clinical data. You know…the ”this is what it looks like and feels like in my everyday reality” perspective. I am so grateful to the author for sharing her experiences so candidly.

The author highlights some of the real challenges associated with clinical nutrition interventions. Humans are not lab mice living in cages and eating mouse chow when it is provided on a schedule set by someone else. You’d have to ask the mice how they feel about this but that is a different conversation altogether…

Outside of the lab, humans have to navigate every day surrounded by food. We have to make choices, respond to the environment in which we find ourselves, and respond to our body’s signals. And based on my experiences with humans and food… we are pretty opinionated about what and when we eat. And often, obstacles arise that interfere with our best laid plans.

The results of this study will impact me personally on two levels. First, I have lived with MS since 2008, and I certainly want less severe disease! Second, as a registered dietitian I help people overcome nutrition challenges. Specifically I want to help people with MS overcome nutrition challenges. Adopting intermittent fasting would present a huge nutrition challenge to anyone. I don’t want to be a Debbie Downer, but I do have a few questions and concerns about this study. Or more specifically, about the nagging real life details hiding “between the lines” of the study that the NPR article illustrated so well.

 

It’s a beginning.

First and foremost I am grateful for a controlled nutrition intervention study… this takes time and money and I am glad that the powers that be are beginning to ask research questions about the role of nutrition in multiple sclerosis. But I am mindful that while the evidence provided in this study may add another piece to the puzzle, it will not likely be the final piece.

 

What, specifically, does less severe disease mean … in humans?

Fewer brain or spine lesions? Better symptom management? Decreased disability? They are all important, but more specific definitions would help an individual to make a risk/reward based decision about whether this intervention is the right one for them.

 

Is intermittent fasting a sustainable practice?

The calories provided to study participants with continuous caloric restriction are equal to 78% of what would be necessary to maintain their current weight. So, that would mean a roughly 350 calorie per day deficit for a person requiring 1600 calories.

Study participants assigned to intermittent fasting would get the same 78% of calories required to maintain their current weight but they would but they would need to consume all calories within an 8-hour window each day and fast for the other 16 hours. They would follow this for for 5 out of 7 days each week.  The other two days they will receive 25% of the calories required to maintain their current weight, or, in the 1600 calorie scenario, 400 calories all day.

The inclusion criteria require a BMI of 23 kg/m2, which is right smack in the middle of a normal weight range. How long could someone with a BMI of 23 restrict calories in this way before they become underweight? What then?

What if this study shows that the intervention is safe, and additional research shows that the practice results in less severe disease in humans? Restrictive diets are challenging even under the best conditions. Is this an eating pattern you could comply with … forever?

The tests on mice did not extrapolate this into a forever scenario. Perhaps intermittent fasting for a finite period of time will sufficiently impact the microbiome and then the timing of calories will no longer matter.

Or it may be that excess body fat is actually the culprit and once enough weight is lost the gut will be “reset” and allow a return to more traditional distribution of calories throughout the day.

Time and research will no doubt answer these questions.  But, if eliminating excess body fat is the goal, it should be noted that these extreme measures are not only unnecessary they can actually be detrimental.

 

Guilt, Shame and Confession

Reducing caloric intake by 350 calories per day for some people is possible by simply making different food and beverage choices. But consuming only 400 calories per day (or whatever 25% of your specific calorie needs are) is not possible without some extreme restrictions.

I can see these caloric restrictions and externally imposed designated times to eat interfering with the body’s innate hunger and fullness cues. The author of the NPR article describes how she experienced this:

 

“I only had a few hours left to eat! I wasn’t hungry, but just to play it safe, I ate a taco and some ice cream.”

 

Her body’s innate sense of protection has her squirreling away food because she anticipates being hungry in the very near future. ? Hmmm…my Spidey senses are tingling.

But the author describes eventually settling into a comfortable eating routine featuring more vegetables as well as including some physical activity. Or until real world obstacles pop up anyway. And who among us does not live in the real world?

In the author’s case it was travel to a wedding. The interruption to her regular schedule made it necessary for her to consume food and beverages outside of the designated hours for eating. This led to:

 

“Hesitantly, shamefully, I confessed to everything.”

 

And there it is… guilt, shame, confession. Yikes.

 

“Compliance” is imperative in a clinical setting to maintain the integrity of the study. “Confessing everything” is necessary in this case. But, I have been around diets long enough to feel really uncomfortable when I hear people feeling ashamed for responding to their body’s hunger messages. This is a hallmark behavior of disordered eating. After getting more acquainted with this study it is clear why people with a history of an eating disorder were excluded from participation.

 

Side effects

Like many other prescriptions you may receive, this intervention comes with some expected side effects. And I am not just talking about how intermittent fasting may impact your bowel regularity.

If this and other research shows that caloric restriction or intermittent fasting are indeed a key requirement for a less severe MS disease course in humans, then prescribing physicians will need to be aware of the implications of this new prescription. Because, in my professional opinion, it will be much easier to prescribe than to implement.

And it will be important to remember that these interventions are not without risks; risks that will need to be weighed with the potential benefits. A responsible prescription for intermittent fasting to lessen MS disease severity should be accompanied by the guidance and support required to ensure this practice is undertaken safely and to prevent a prescribed disordered eating practice from triggering an eating disorder. I discourage anyone from undertaking intermittent fasting without medical supervision.

Like you, I look forward to the results of this and other research tat is finally looking at the role of nutrition in living well with MS. But research is slow… and life moves fast. You do not have to wait for the results of this study to eat healthier. Make choices every day that help you feel better. Eat color at every meal.Eat when you are hungry. Move your body every day.

 

Eating should not result in guilt, shame or the need to confess anything.