The Role of Nutrition in Multiple Sclerosis

As a registered dietitian nutritionist (RDN) living with multiple sclerosis, I am no stranger to questions about the best way to eat, and general questions about nutrition with multiple sclerosis. A quick Google search provides a lot of information and links to “diets”, “programs” or “protocols” that make a lot of promises and are promoted to be beneficial for individuals with multiple sclerosis. There are lists of foods that you should avoid, lists of foods that you should eat huge amounts of, there are long lists of supplements that you should take.

What they often fail to make clear is that these recommendations have not been rigorously tested and have little or no science to support their claims. In fact, at present MS has no known cause and no known cure. Many have speculated that poor (“Western”) diet is at least part of the cause. Unfortunately there has been very little research investigating the role of diet and the development of multiple sclerosis. The research that does exist on this matter is often inconsistent and limited by narrow focus or small sample size. The truth is that it is very challenging and expensive to conduct randomized controlled nutrition research, thus very little has been conducted.

I should provide full disclosure here… I am not a fan of “diets”, “programs” or “protocols” as a general rule. Many make false claims or overstate the science behind their theories, many rely on personal accounts or testimonials due to lack of supporting evidence and most exist primarily to separate you from your money. Almost all diets or programs will include some good or beneficial advice.

But many make recommendations that are not supported by any evidence, are not sustainable and can be expensive. When a diet, program or protocol suggests, for example:

• “You have to completely overhaul the way you eat!”
• “The foods you and everyone you know eat regularly are toxic!”
• “You are encouraged to severely restrict or avoid macronutrients completely!” (think carbohydrate, protein, fat)
• “The purchase of their books, supplements, program etc will ensure that you will have success!”
•  “A daily regimen of supplements is an important part of the nutritional strategies for MS. They are completely safe and have the potential to be of significant benefit”. Potential for benefit? What about potential for harm?
• “That you should be taking large quantities of ‘designer supplements’ to “bolster immune regulation, to increase anti-oxidant capacity and to avoid deficiencies.”
• Their diet, plan, program or protocol  can “reverse”, “cure”, “overcome”, “beat” MS or any other disease.
• …this should be a red flag to you! What exactly does overcome, beat, reverse, cure, mean in the context of a disease with no known cause and no known cure?

Immune Mediated Process:

The National MS Society defines Multiple Sclerosis this way:

“Multiple sclerosis (MS) involves an immune-mediated process in which an abnormal response of the body’s immune system is directed against the central nervous system (CNS), which is made up of the brain, spinal cord and optic nerves. The exact antigen — or target that the immune cells are sensitized to attack — remains unknown.

One of the most challenging features of MS is the fact that each person experiences the disease so differently, including the symptoms we deal with. In my opinion, this concept alone should plant a seed of doubt about a diet or protocol that purports to address such a vast array of complications. One size does not fit all.

So does this mean that diet plays NO role in helping me live better with MS? Absolutely not!

According to the information presented by Dalia Rotstein, MD Clinical Fellow in Neurology, Brigham and Women’s Hospital at the 2014 Joint American and European Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS/ ECTRIMS) there is currently no evidence of an association between poor diet and MS. (Neurology Reviews. 2014 22(11):55) However, at the same meeting, evidence was presented showing that people with comorbidities (The presence of more than one disease or condition in the same person at the same time) experience decreased quality of life and an increase in disability. Some of the most common comorbidities associated with MS include:

• Heart Disease
• Congestive Heart Failure
• High Blood Pressure
• High Cholesterol
• Stroke
• Cancer (Cervical, Breast, Meningioma, Digestive And Urinary Cancers)

While, at present, there is no concrete evidence to suggest a specific dietary pattern that is beneficial for MS, there is abundant evidence to support diet and lifestyle modifications known to reduce risk factors for the comorbid conditions. In other words eat for health generally, not MS specifically and in doing so you improve your quality of life and decrease your risk of disability.

But what about inflammation?

Relapsing remitting MS (RRMS), secondary progressive MS (SPMS) and primary progressive MS (PPMS) are all characterized by chronic inflammation. “Inflammation” happens to be a diet buzzword at the moment as well and we are all hearing that various foods are either “pro-inflammatory” or “anti-inflammatory”. But exactly how does a food impact inflammation in the body? This recent article published in The American Society for Neurochemistry addresses that question. The authors outline and describe two pathways by which food can impact the course of inflammatory diseases in the body: metabolism and the gut.

From a metabolic standpoint, the nutrients provided by the food we eat can impact metabolic pathways where the nutrients are manipulated, modified, and molded into molecules the body can use. The quality of the nutrients determines what kinds of molecules are created; some can be pro-inflammatory while others are anti-inflammatory in function.

From a gut standpoint, the article considers the impact of diet and lifestyle on the gut microflora. They suggest that certain dietary patterns contribute to [simple_tooltip content=’Gut dysbiosis is an imbalance in the intestinal bacteria that can cause changes in the normal activities of the gastrointestinal tract possibly resulting in health problems.’]“gut dysbiosis”[/simple_tooltip] (sometimes referred to as “leaky gut“, another current buzz word) which is thought to contribute systemic inflammation. Alternatively there are dietary patterns associated with [simple_tooltip content=’Gut eubiosis is a state of a dynamic equilibrium of the microflora in stomach and intestinal tract’]“gut eubiosis”[/simple_tooltip] which is desirable and associated with decreased inflammation. It is worth noting that at this time, the association between gut microbiota and MS has only been shown in mice.

The authors suggest the following:

Pro-inflammatory diet pattern includes:

• Saturated Animal Fats
• Trans Fats & Hydrogenated Fats
• Red Meat
• Hyper-caloric Diets including sweetened drinks, refined carbohydrates
• Increased Dietary Salt intake
• Cows Milk Fat Proteins – If you are a milk drinker and have concerns, opting for skim milk avoids the problem, if it exists. You could also opt for one of the many non-dairy milks available. (There is some conflict here—some studies suggest it is harmful; others suggest it confers protective benefit.)

Anti-inflammatory diet pattern includes:

• Polyphenols: group of colorful phytochemicals, many of which are antioxidants.
• Carotenoids: natural pigments synthesized by plants and many micro-organisms. They give yellow and red-orange fruits and vegetables their color.
• and other Phytochemicals (plant chemicals that have protective or disease preventive properties) from fruits, vegetables, whole grains, spices, tea and coffee. Food sources are the best way to consume these nutrients and a variety is important for a synergistic effect (when something is synergistic it means various parts are working together to produce an enhanced result)/
• Omega 3 Fatty Acids  from fish and other (plant) sources and Alpha Lipoic Acid from animal and plant sources
• Sufficient intake of  Vitamins D, A, C, B12
• Sufficient selenium and other important minerals

So, while science has not yet identified a proven MS Diet, there are some dietary habits that have been associated with better health outcomes. And as it happens the recommendations made by the American Heart Association , The American Stroke Association and the American Institute for Cancer Research (AICR)  linked with better outcomes for the commonly associated comorbidities like cancer, stroke and heart disease line up nicely with the anti-inflammatory diet pattern outlined above. Which means that   using  these recommendations as a guide you are likely to improve your overall health, reduce your risk of comorbid diseases associated with MS, limit dietary contributions to inflammation. Win, Win.

Hold on!  You didn’t mention gluten…..

Gluten has been blamed for the rise in a number of diseases, including MS. However, a celiac diagnosis is still rare and there is no evidence of increased prevalence of gluten sensitivity in patients with MS.  If you are concerned about a gluten allergy you should talk to your doctor about getting tested for celiac disease. You can read more about Non-Celiac gluten sensitivity here & here. There are some anecdotal reports that people feel better after giving up gluten. While it is possible to eat a nutritionally adequate diet while avoiding gluten, there are some things you will want to consider.

A few things to keep in mind if you are avoiding gluten in your diet:

• Perhaps you feel better because gluten-laden processed foods in your diet been replaced with basic, nutrient-dense, whole foods.
• Remember that just because a packaged food is labeled “gluten free” does not mean it is healthy. Many packaged gluten free foods are very highly refined foods.
• You may be sensitive to FODMAPs not gluten. FODMAPs are FODMAPs are a collection of short chain carbohydrates and sugar alcohols found in foods naturally or as food additives.
• Because gluten free foods are not subject to the same fortification standards as conventional foods, make sure to get adequate food sources of fiber and B Vitamins to prevent a deficiency.

Nutrition and wellness tips for people living with Multiple Sclerosis:

• Avoid extreme, expensive or untested diets that make big promises. Talk to your doctor or a registered dietitian if you have questions.
• Don’t Smoke.
• Exercise regularly. This will benefit your overall health as well as help manage some specific MS related symptoms like fatigue, depression and bladder & bowel control. Go here for more information about MS and exercise.
• Get good sleep. Sleep disturbance is a big contributor to fatigue.
• If you consume alcohol, do so in moderation. One drink per day for women and 2 drinks per day for men. Consumed in excess, alcohol interferes with the metabolism of B vitamins (and thus energy production) and lead to dehydration. 
• Consume nutrient dense vegetables, fruits, whole grains and lean proteins (Plant, seafood or animal proteins based on your preference).
• Don’t regularly consume more calories than you use. This can lead to excess body fat, increasing your risk for comorbid diseases. It also contributes to systemic inflammation as much or more than any “pro-inflammatory” food.
• Limit or avoid added sugars.
• Lower your sodium intake, both from the salt shaker and from sodium hidden in refined, processed convenience foods. Research has shown high intake of dietary sodium may be linked to increased disease activity.
• Choose foods that provide healthy fats (Omega 3, MUFA, PUFA) and avoid saturated fats, trans fats and hydrogenated fats.
• Consume food sources of pre and probiotics. Read my articles on Probiotics, Prebiotics, and Synbiotics here and  here.
• Because MS is associated with a greater risk of fractures, bone health is very important. Sufficient protein intake along with adequate Calcium, Vitamin D and other minerals that support bone health. Read my articles about Calcium here and here.  Read my article about Magnesium here.
• Do not opt for a diet, program, or protocol in place of disease modifying medications. Food Is medicine, right? NO. Food is food and medicine is medicine. A healthy diet can improve your health and help you manage symptoms and side effects, but it will not cure MS.

Should I take supplements?

• It is much better to get your nutrients from food because of the synergistic impact. However if there is a deficiency, a supplement might be warranted.
• B12 supplements are advised for vegans, as this important nutrient is found only in animal foods.
• Vitamin D, Calcium: Research is increasingly pointing to Vitamin D deficiency as a risk factor for developing MS, and studies are ongoing to determine if vitamin D levels influence MS disease activity.  You should ask your doctor to test your blood levels of vitamin D (Serum 25-Hydroxyvitamin D [25(OH)D] ). If your level is deficient taking a supplement is a good idea. However, mega-dosing Vitamins is not recommended. Talk with your doctor or registered dietitian if you have questions about this.
• If you do take supplements of any kind, be mindful of the fact that vitamins and supplements are not regulated.   Recall that recently several retailers had to remove supplements from their shelves because they contained something other than what they were supposed to contain; read more about that here. Be careful what you choose. When people see a supplement stating “it is an all natural product, so how bad can it be?” I like to remind people: hurricanes and tsunamis are products of nature as well, and they can do a great deal of damage. Vitamins and supplements do have a place in our quest for optimal health, but food is the way our bodies prefer to get nutrients.  With supplements, less is usually more and the manufacturer details really matter. Choose wisely and make sure your doctor and or pharmacist is aware of what you are taking to prevent any possible drug interactions.

Final thoughts:

Many of the “diets” promoted for MS involve extremes in one way or another. Expensive foods, mega-dosing vitamins, very strict guidelines of what to eat what not to eat, macronutrient extremes… in other words very different from the way most people and the families they share meals with might find enjoyable, practical and affordable. There is no diet proven to be beneficial for MS but there is a dietary pattern proven to be beneficial to health. I recommend we eat for health to live better with MS.