MS, Diet And Research; One Piece Of The Puzzle At A Time
As a nutrition professional living with MS, I am as hopeful as the next person that a cure for MS is in the very near future. I am also extremely happy that the powers that be (think money) are beginning to support interventional studies involving diet in human subjects …something that is pretty scarce. But research takes time; lots of time and not all studies are created equal. It is a lot like piecing together a very complicated jigsaw puzzle. It is important to understand a few things about the research you are reading about. What kind of study is it? Who is paying for the study? Is there a conflict of interest? Are the subjects human? How many subjects are there? What is the outcome measure? Are the results applicable to everyone with (each type of) MS? This website offers a comparison of different research study designs.
There is a new study funded by the MS Society that is comparing the Swank Diet to the Wahl’s Protocol. Read about it here (and here for an article that raises some important questions about the study). Will the results from this study offer definitive guidance on what people with MS should and should not eat? No. The limited focus of this study will evaluate the ability of two different dietary approaches to reduce MS-related fatigue in 100 participants with RRMS. The primary outcome measure is participant fatigue but researchers will also track their physical activity, nutritional status, mobility, cognition, and mood, and will also be monitored for potential side effects. Unlike many such studies, this study will not have a control diet by which the two are compared.
Fatigue is a debilitating symptom of MS but is one of many symptoms. What are you to take from this study if you have MS but fatigue is not your most troubling symptom? Nothing really as MS related fatigue is the primary outcome measure. What should you take from this study if you have primary or secondary progressive MS? Answer: Nothing really as this study only looks at relapsing remitting MS and does not allow for possible differences in the response of relapsing versus progressive participants.
One million dollars and 4 years to determine the impact of these two dietary patterns on fatigue on a group of 100 people with relapsing remitting multiple sclerosis. Just one (very) small piece of the puzzle….
There was a recent small phase 1 intervention study evaluated the impact of a low-fat plant based diet in 61 study participants with relapsing remitting MS (RRMS). The primary outcome measure: the number of new brain lesions as seen on MRI. Secondary outcome measures: relapse rate and disability progression, fatigue, depression and quality of life. Results: although there were symptom improvements, there was no improvement of lesion activity as seen on MRI, relapse rate or disability as assessed by the EDSS scores. Does this mean a plant-based diet is unhealthy for people with MS? No, it just means that it did not reduce relapse rate or disability in these 61 people as assessed by EDSS. Does a negative result count as a piece of the puzzle? Maybe?
Something important to keep in mind about research studies in general.
Not all research studies will provide sweeping and definitive information! In fact, many have a very narrow focus and may only elucidate a small piece of information that is important to the bigger picture. That small bit of new information may provide actionable information or (more likely) provide the starting point for the next research question. There are a number of clinical trials currently underway are looking at various ways that diet, dietary components or food delivery methods impact immune function and the course of the MS disease process. They may all seem narrow but is it possible that one of these studies will be the piece of the puzzle that helps all of the others to come together?
This clinical trial is following up on a mouse study, which found that high salt diets had a significant effect on the course of EAE, the mouse model of multiple Sclerosis. The study is evaluating the association between high sodium diet and TH17 and interleukins (immune function cells) in healthy human male subjects (females will be studied in a later study). Interventions: low salt diet, low salt diet with IV saline, high salt diet. Primary outcome measures: Th17 levels, Secondary Outcome Measures: Interleukin levels. The study subjects are not MSers but the information gained here may provide important information about immune function cells and the MS disease process. Another small piece of the puzzle.
There is another clinical trial investigating the influence of dietary salt intake on immune function in MS subjects and healthy control subjects. You can read about that here.
There is a clinical trial that is utilizing a Caprylic Triglyceride medical food for treatment of cognitive impairments in people with MS. You can read more about it here. The primary outcome measure of this study is a “Change in Total Learning” as evidenced by performance on specific tests. Cognitive problems are another frustrating symptom experienced by many with MS. Hopefully the results of this study will provide another piece of the puzzle.
Some studies are trying to determine if cycling between periods of eating and periods of fasting has an impact on MS. Determining the safety and efficacy of conducting such research has been the primary outcome measure of these early studies. I wrote about one of them here. You can read about others here and here.
Several studies are beginning to evaluate the role of the gut microbiome in MS. Some of the areas of study presented recently at the 2016 European Committee for Treatment and Research In Multiple Sclerosis (ECTRIMS) included:
- A study of the role of polysaccharide A (PSA) gut-related molecule called polysaccharide A (PSA) in EAE, the mouse model of MS. This piece of the puzzle takes us one step closer to future clinical studies to explore how PSA may help to stop the immune attack in people with MS. Read more here.
- The important ways that gut bacteria differ in people with MS – specifically bacteria that may drive immune system activity in MS and others that can suppress it. Read more here.
- One study showed that Th17 cells are increased in the gut of people with MS compared with people who do not have MS. (Th17 are the same immune cells that a high salt diet may impact…). Read more here.
- The discovery of some important links between types of gut bacteria and specific immune markers in children with MS. Read more here.
This research is just beginning to put the gut / microbiome portion of the puzzle into perspective, which is an important step in the right direction! I would caution anyone pursuing any supplements or other regimens purported to address this issue as there isn’t even a full understanding of the connection much less what the fix is. Manage your expectations, save your money. And remember, it is important to share any supplements you take with your healthcare team.
So, What Is The Takeaway Message Here?
An important takeaway message about MS and Diet is that it is entirely possible that there will not be a single diet (Paleo versus Swank for example) that will benefit everyone living with all types of multiple sclerosis! Read that sentence one more time and let it sink in a bit. As I mentioned in this article about anecdotal evidence; even before we consider an individual’s full medical history (which will be different for everyone), everyone absorbs medications and nutrients a little differently. And these variables change in everyone over their lifespan—you don’t absorb or utilize nutrients at age 18 the same as you do at 40 or as you do at 70. So, logically speaking, a single diet will not have the same impact on everyone who adopts it. It may just be that a dietary component (think sodium, or caprylic triglyceride, gut bacteria) rather than a regimen or pattern will be the thing that impacts everyone with all kinds of MS. Or it may be some complex combination of all of these factors. It may also be that what works for one individual will always be less effective for another individual and vice versa. It may be that an individualized approach will always be most effective.
As I said, research takes time. The results of the MS Funded study looking at diet and fatigue will be available in 4 years. Some of the research on sodium will conclude in the next year. Other studies will no doubt be started. But rather than wait for any one of these small studies to be the final word on diet and MS, it may be helpful to think of them as single pieces of a very large and complicated puzzle… you know the kind I am talking about… the 1000 piece puzzle with lots of pieces with similar looking background. The ones that are challenging and take a long time to put all of the pieces together. It is a slow, methodical and expensive process…
What To Do In The Meantime?
The diet and habit guidelines supported by the American Heart Association , The American Stroke Association, The American Diabetes Association and the American Institute for Cancer Research (AICR) are linked with better health outcomes for many of the chronic health conditions common in people living with MS. By following these recommendations you are likely to improve your overall health, reduce your risk of comorbid diseases associated with MS. And by doing so you may improve your quality of life and reduce your risk of disability.
Here is a brief summary of these recommendations:
- Eat a variety of nutrient dense foods including:
- Lean proteins
- Colorful vegetables and fruits
- Whole grains
- Beans and legumes
- Nuts and seeds
- Foods rich in omega 3 fatty acids
- Foods rich in calcium
- Eat less of these foods that offer few benefits:
- Foods and beverages high in calories but low in nutrients.
- Limit or avoid added sugars.
- Reduce sodium intake. From the salt shaker as well as from sodium contained in refined, processed convenience foods.
- Limit the amount of saturated fat that you eat. Avoid trans fats entirely.
- Don’t regularly consume more calories than you use. Doing so can lead to excess body fat which can increase your risk for comorbid diseases and contribute to systemic inflammation.
- Limit consumption of alcohol
- Be physically active
- Don’t smoke
If cognitive function is a specific concern for you, check out how the recommendations of the MIND Diet tweaks the above guidelines just a bit to reduce risk factors for cognitive decline and Alzheimer’s disease.