I am a registered dietitian (RDN) who was diagnosed with MS in 2008. Prior to my diagnosis, I had read very little on the subject of Nutrition and MS. I had read enough to know that there was no evidence to support a specific diet to beat, cure or reverse MS. I also knew that no food or nutrient that if avoided completely or consumed in copious amounts would beat, cure or reverse MS. My experience working with cancer patients also taught me that there was (and still is) a lot of sketchy information available on the Internet and elsewhere. It is important to investigate any claims made by products or practitioners promoted on the Internet and elsewhere. Go here and here for tools that can help you to evaluate health claims.
Since my diagnosis, I have read pretty extensively on this subject and have found that there are many things that we can do with our food and lifestyle choices to help us live better, healthier lives with MS. Overall good health and wellness matters! There is a compelling argument to be made for avoiding obesity and the chronic health conditions associated with obesity. Doing so can improve the quality of your life and decrease the likelihood of disability with MS. If you are living with MS and searching for a way to live better with MS you should consider the argument outlined in the article below.
What is Obesity, exactly?
Obesity is an abnormal accumulation of body fat, usually 20% or more over an individual’s ideal body weight. Obesity is a serious and increasingly common condition associated with increased risk of illness, disability, and death. Obesity is a risk factor for many major health problems including:
- Heart Disease
- High Blood Fats
- High Blood Pressure
- Metabolic Syndrome
- Obstructive Sleep Apnea
- Certain Cancers
- Multiple Sclerosis
Who Does Obesity Impact?
- More than 30% of the US adult population is considered to be obese.
- More than 1 in 20 (6.3 percent) have extreme obesity.
How Does Obesity Impact Multiple Sclerosis?
While studies of nutrition in general and nutrition related issues for people with MS specifically are limited, there is a growing body of research that suggests obesity may contribute to the incidence of MS. And, obesity is associated with the progression of disability in people who already have MS.
Obesity In Adolescence
Results of several recent studies suggest that obesity, or specifically a higher Body Mass Index (BMI), during adolescence may be a risk factor for the development of MS. And when MS does develop in people with high adolescent BMI, symptoms occur at an earlier age.
Obesity In Adults With MS
Meaningful randomized controlled studies to investigate the benefits or harm of nutrition on human health require a LOT of time and money and are very challenging to conduct– so they don’t get done often. Would you dedicate a decade or more of you life to a specific dietary pattern to contribute to the evolution of scientific understanding? Would thousands of others? Who would pay for it? What if the dietary pattern turned out to be harmful rather than beneficial? Time consuming, expensive and complicated.
But, that doesn’t mean that there is no research available. The results of an increasing number of cohort and cross sectional studies involving people with MS and various dietary related metrics suggest that diet and lifestyle do play a role in multiple sclerosis. This information supports the assertion that overall health and the role that nutrition plays in this matters. A LOT. Especially when you have a chronic health condition like MS. There is a longstanding association between excess body weight and adverse health outcomes. The outcomes may be more adverse when obesity related diseases are added to multiple sclerosis. The results of these cohort and cross sectional studies may prompt MS specific nutrition trials in the future. But until then, there is plenty of actionable information available that encourages living a healthy lifestyle.
Multiple Sclerosis And Obesity, What You Need To Know:
There Are Risks Associated With Obesity And MS:
- Inflammation: Obesity contributes to chronic low-grade inflammation and release of cytokines that influence immune response.
- Vitamin D Deficiency: Obesity is known to contribute to Vitamin D deficiency. Vitamin D plays several important roles in our body. It promotes calcium absorption in the gut and maintains adequate calcium and phosphorus levels in the blood. It is required for bone growth and helps to prevent osteoporosis. Vitamin D also has a role as an immune function regulator. Read my article about the importance of bone health with MS here.
- Insulin Resistance, Metabolic Syndrome, and Diabetes: Obesity is the most common cause of insulin resistance, which the body has a decreased response to insulin, which causes the body to produce larger quantities of insulin to maintain blood glucose levels. Insulin Resistance is associated with chronic inflammation and oxidative stress, two things it would be good to avoid with MS. Waist circumference (belly fat) is a better indicator of risk for insulin resistance than BMI. This may be especially true in people with disabilities.
- Metabolic Syndrome (which is a cluster of conditions — increased blood pressure, a high blood sugar level, excess body fat around the waist and abnormal cholesterol levels — that occur together, increasing your risk of heart disease, stroke, and diabetes). Metabolic syndrome is associated with increased risk of death from heart attack and stroke as well as all-cause mortality. Characteristics of Metabolic Syndrome include Hyperinsulinemia (the amount of insulin in the blood is considered higher than normal) and an elevated level of inflammatory cytokines and C-reactive protein. Hyperinsulinemia is associated with cognitive impairment. Insulin resistance can lead to prediabetes, when the beta cells can no longer produce enough insulin to overcome insulin resistance, causing blood glucose levels to rise above the normal range. Once a person has prediabetes, continued loss of beta cell function usually leads to type 2 diabetes. Diabetes may increase susceptibility to oxidative stress and increase inflammatory response in the brain.
- Vascular Comorbidities including Heart Disease, Hypertension, and High Cholesterol: Vascular comorbidities are common with MS—just as they are in the general population—and they are independently treatable. Having vascular comorbidities with MS significantly increases the risk of disability. This is true regardless of whether the comorbidities were present at the time of MS diagnosis or came along later. One cohort study found that the risk of early gait disability increased by 50% per comorbidity so having more than one could have a tremendous impact on quality and quantity of life. Changes to diet and lifestyle can have a big impact on these risk factors.
- High Blood Fats: Associations between high blood fats and increased inflammation are well established in atherosclerosis, heart disease, metabolic syndrome, obesity, and Lupus. A study of 492 MS patients found that elevated blood fats have a modest impact on disease progression in MS. High LDL, triglycerides and total cholesterol levels (bad cholesterol) were associated with worsening disability while higher HDL cholesterol (good cholesterol) was associated with lower levels of acute inflammatory activity. Weight loss and physical activity have a positive effect oh HDL. Diet and lifestyle modifications can improve your blood fat profile.
- Obstructive Sleep Apnea (OSA): OSA is a well-recognized health challenge in this country and it is common in people with MS. The most common cause of obstructive sleep apnea is excess weight and obesity. Sleep disturbance in general and OSA specifically is a significant contributor to fatigue in people with MS. Fatigue is the most common and one of the most debilitating symptoms reported by people with MS. Read my article about the role of diet in MS fatigue here.
- IBS: GI symptoms are common in people with MS. Obesity is linked to IBS but no causal relationship has been established. Diet and lifestyle choices can address a number of GI symptoms, including IBS.
- Arthritis: The strain that extra weight places on the body can result in pain and arthritis. Obesity induced inflammatory cytokines may contribute to osteoarthritis and rheumatoid arthritis. Check out this interesting article by the Arthritis Foundation. Although it does not address multiple sclerosis, the article supports the importance of maintaining a healthy weight with arthritis.
- Depression: Inactivity, poor diet and comorbid health conditions have significant links to both obesity and depression in people living with MS. Obese participants in one study were 1.5 times more likely to screen positively for depression.
Multiple Sclerosis is a disease with a poorly understood diversity of outcomes. Comorbidity might potentially explain this diversity.
The Comorbidity Conundrum: Having another condition at the same time is known as comorbidity. Evidence suggests that people with MS who have one or more comorbidities experience decreased quality of life and an increase in disability. MS is a disease with a poorly understood diversity of outcomes. Comorbidity might potentially explain this diversity. Reducing risk factors for comorbid conditions and/or optimizing the management of comorbidities will not cure MS but will certainly improve overall health and quality of life—especially when living with multiple sclerosis.
So … If I could provide only one bit of nutrition-related advice to people living with MS, what would it be?
I would tell people to Think BIG… big picture that is. Sustained diet and lifestyle modifications are far more important to your overall health than avoiding a specific ingredient or taking a specific supplement. Be as healthy as you can be! A healthy diet and healthy daily habits (aka lifestyle) will not cure MS. True enough! But diet and lifestyle modifications including attaining and maintaining a healthy weight can greatly improve the quality and quantity of your life.
Obesity is a Modifiable Risk Factor for all of the health conditions listed above. Modify your Diet and Lifestyle to limit obesity and risk factors for comorbid health conditions!
Change is always difficult and there are really no shortcuts; you have to actually make sustainable changes. BUT the payoff for your hard work is promising! Losing excess weight can make you feel better both physically and emotionally. Even a modest weight loss of 5%-10% of your starting weight can lead to significant health benefits.
My diagnosis has changed a lot about my life personally and professionally. I am aware that people with MS have a lot of questions about nutrition and are in general underserved in this regard. I am also more aware of the vast amount of unreliable information available that is targeted at you and I. On the first day of the MS Challenge Walk in Cape Cod an interviewer who recognized that I had identified myself as a first-time walker with MS asked me if any good had come out of my diagnosis. I thought that was kind of a silly question until I realized my professional life has taken a new direction and I am passionate about helping people with MS gain a better understanding of how nutrition can improve the quality of their lives. This is a good thing that has come out of my diagnosis. When life gives you lemons, make lemonade.
Here is a bit more information to help you determine if your BMI or waist circumference put you at risk for comorbid health conditions. Also some specific guidelines on physical activity to help you establish your daily physical activity habit!
Adults (aged 18–64)
- Adults should do 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes (75 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week.
- Additional health benefits are provided by increasing to 5 hours (300 minutes) a week of moderate-intensity aerobic physical activity, or 2 hours and 30 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both.
- Adults should also do muscle-strengthening activities that involve all major muscle groups performed on 2 or more days per week.
- Older adults (age 65 and older) should follow the adult guidelines. If this is not possible due to limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Older adults should do exercises that maintain or improve balance if they are at risk of falling.
- For all individuals, some activity is better than none. Physical activity is safe for almost everyone, and the health benefits of physical activity far outweigh the risks. People without diagnosed chronic conditions (such as diabetes, heart disease, or osteoarthritis) and who do not have symptoms (e.g., chest pain or pressure, dizziness, or joint pain) do not need to consult with a health care provider about physical activity.
Adults With Disabilities
- Follow the adult guidelines. If this is not possible, these persons should be as physically active as their abilities allow. They should avoid inactivity.
BMI and Waist circumference are both measures of obesity. BMI is an estimate body fat based on your weight in relation to your height, and applies to most adult men and women aged 20 and over. You can ask your doctor or dietitian to help you determine your BMI or try the National Heart, Lung, and Blood Institute’s (NHLBI’s) online BMI calculator.
If your BMI is:
- Less than 18.5, it falls within the underweight range.
- 5 to 24.9, it falls within the normal or Healthy Weight range.
- 0 to 29.9, it falls within the overweight range.
- 30.0 or higher, it falls within the obese range.
One of the limitations of BMI is that it may underestimate body fat in older persons and others who have lost muscle mass. For example an active athlete with large muscle mass and very little body fat may have a high BMI. Conversely an inactive elderly or disabled person with low levels of muscle and bone mass may have a BMI in the normal range, even though they have quite a lot of body fat in comparison to their lean body mass (muscles).
The measurement of waist circumference compares closely with your BMI and is a simple check to tell how much body fat you have and where it is placed around your body. Waist circumference is often seen as a better way of checking your risk of developing a chronic disease. Central adiposity (“belly fat”) has been associated with adverse health outcomes. Given that loss of muscle mass is likely to impact BMI an increasing body of research suggests that waist circumference may be a more a more accurate measure of health risk in individuals with disabilities.
Waist circumference measurement is particularly useful in people who are normal or overweight on the BMI scale but it has little added predictive power of disease risk beyond that of BMI in people with a BMI ≥ 35.
How to measure waist circumference
- Remove clothing from your waistline.
- Stand with feet shoulder width apart (about 10-12 inches) and back straight.
- Locate the top of your hipbone. This is the part of the hipbone at the side of the waist not at the front of the body. Use the area between the thumb and index finger to feel for the hipbone at the side of the waist.
- Align the bottom edge of the measuring tape with the top of the hipbone. Wrap the tape measure all the way around the waist. Ensure that the tape measure is parallel to the floor and not twisted.
- Take 2 normal breaths and on the exhale of the second breath tighten the tape measure so it is snug but not digging into the skin.
- Take the measure of the waist to the nearest 0.5 cm (1/4 inch).
Waist Circumference Measurements Associated With Increased Health Risks:
- If you are a male and your waist circumference is > 40 inches
- If you are female and your waist circumference is > 35 inches
If I were asked to provide a second bit of nutrition advice to people living with MS it would be to limit salt consumption…..There is increasing evidence that a a diet high in sodium may increase MS disease activity. I wrote a bit about that here and will provide updates as new information becomes available. Thanks for stopping by! Feel free to email me if you have any questions regarding MS and Nutrition.
Read my follow up to this article here.
- Alschuler KN, Gibbons LE, Rosenberg DE, Ehde DM, Verrall AM, Bamer AM, Jensen MP. Body mass index and waist circumference in persons aging with muscular dystrophy, multiple sclerosis, post-polio syndrome, and spinal cord injury. Disabil Health J. 2012 Jul;5(3):177-84.
- Braley TJ, Segal BM, Chervin RD. Obstructive sleep apnea and fatigue in patients with multiple sclerosis. J Clin Sleep Med. 2014 Feb 15;10(2):155-62.
- Health.gov Physical Activity Guidelines http://health.gov/paguidelines/
- Hedström AK, Olsson T, Alfredsson L. Body mass index during adolescence, rather than childhood, is critical in determining MS risk. Mult Scler. 2015 Sep 11
- I-Min Lee, Eric J Shiroma, Felipe Lobelo, Pekka Puska,Steven N Blair, and Peter T Katzmarzyk, for the Lancet Physical Activity Series Working Group
- Impact of Physical Inactivity on the World’s Major Non-Communicable Diseases Lancet . 2012 July 21; 380(9838): 219–229.
- Kavak KS, Teter BE, Hagemeier J, Zakalik K, Weinstock-Guttman B. New York State Multiple Sclerosis Consortium. Higher weight in adolescence and young adulthood is associated with an earlier age at multiple sclerosis onset. Mult Scler. 2015 Jun; 21(7):858-65.
- Marrie RA, Elliott L, Marriott J, Cossoy M, Blanchard J, Leung S, Yu N. Effect of comorbidity on mortality in multiple sclerosis. Neurology. 2015 Jul 21;85(3):240-7
- Marrie RA, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. Comorbidity delays diagnosis and increases disability at diagnosis in MS. Neurology. 2009 Jan 13;72(2):117-24.
- Marrie RA, Reider N, Cohen J, Trojano M, Sorensen PS, Cutter G, Reingold S, Stuve O. A systematic review of the incidence and prevalence of sleep disorders and seizure disorders in multiple sclerosis. Mult Scler. 2015 Mar;21(3):342-9.
- Marrie RA, Rudick R, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. Vascular comorbidity is associated with more rapid disability progression in multiple sclerosis. Neurology. 2010 Mar 30;74(13):1041-7.
- Munger KL, Bentzen J, Laursen B, et al. Childhood body mass index and multiple sclerosis risk: A long-term cohort study. Mult Scler 2013; 19: 1323–1329.
- NIH: National Institute of Diabetes and Digestive and Kidney Disease Overweight and Obesity Statistics http://www.niddk.nih.gov/health-information/health-statistics/Pages/overweight-obesity-statistics.aspx accessed Nov 15, 2015.
- Oliveira SR, Simão AN, Kallaur AP, de Almeida ER, Morimoto HK, Lopes J, Dichi I, Kaimen-Maciel DR, Reiche EM. Disability in patients with multiple sclerosis: influence of insulin resistance, adiposity, and oxidative stress. Nutrition. 2014 Mar;30(3):268-73.
- Overs S, Hughes, CM, Haselkorn JK, Turner AP. Modifiable comorbidities and disability in multiple sclerosis. Curr. Neurol. Neurosci. Rep. 2012.12, 610–617.
- Pinhas-Hamiel O, Livine M, Harari G, Achiron A. Prevalence of overweight, obesity and metabolic syndrome components in multiple sclerosis patients with significant disability. Eur J Neurol. 2015 Sep;22(9):1275-9.
- Salem R, Bamer AM, Alschuler KN, Johnson KL, Amtmann D.Obesity and symptoms and quality of life indicators of individuals with disabilities. Disabil Health J. 2014 Jan;7(1):124-30.
- Taylor KL, Hadgkiss EJ, Jelinek GA, Weiland TJ, Pereira NG, Marck CH, van der Meer DM. Lifestyle factors, demographics and medications associated with depression risk in an international sample of people with multiple sclerosis. BMC Psychiatry. 2014 Dec 3;14:327.
- Veauthier C, Gaede G, Radbruch H, Wernecke KD, Paul F. Sleep Disorders Reduce Health-Related Quality of Life in Multiple Sclerosis (Nottingham Health Profile Data in Patients with Multiple Sclerosis). Int J Mol Sci. 2015 Jul 21;16(7):16514-28.
- Vimaleswaran KS et al. Causal relationship between obesity and vitamin D Status: Bi-directional Mendelian randomization analysis of multiple cohorts. PLoS Medicine. Volume 10, February 2013, p. e1001383.
- Weinstock-Guttman B, Zivadinov R, Mahfooz N, Carl E, Drake A, Schneider J, Teter B, Hussein S, Mehta B, Weiskopf M, Durfee J, Bergsland N, Ramanathan M. Serum lipid profiles are associated with disability and MRI outcomes in multiple sclerosis. J Neuroinflammation. 2011 Oct 4;8:127.
- Wens I, Dalgas U, Deckx N, Cools N, Eijnde B. Does multiple sclerosis affect glucose tolerance? Mult Scler. 2013 Dec 17;20(9):1273-1276.
- Wortsman J, Matsuoka LY, Chen TC, Lu Z, Holick MF. Decreased bioavailability of vitamin D in obesity. Am J Clin Nutr. 2000 Sep;72(3):690-3.