Multiple sclerosis (MS) is a chronic autoimmune disease affecting the central nervous system (CNS), characterized by demyelination of nerve cells. This inflammatory process leads to gradual and permanent neuronal damage, often resulting in neurodegeneration. While there is currently no cure for MS, nutritional prevention and diet therapy hold significant promise for patients, alongside effective pharmacotherapy. This article explores the impact of diet and lifestyle on MS, examining various dietary patterns and lifestyle changes that may help manage symptoms, slow disease progression, and improve overall quality of life.
Understanding Multiple Sclerosis
MS primarily affects individuals between the ages of 20 and 40, with an average diagnosis age of 32. Women are disproportionately affected, with a global rate twice that of men. While the exact mechanisms of MS remain unclear, genetics, infections, and environmental factors are believed to play a role. The disease is more prevalent in North America, Western Europe, and Scandinavia, suggesting a possible link to regional dietary habits and lifestyle factors.
The Western lifestyle, characterized by low physical activity, poor eating habits, high intake of saturated fatty acids (SFAs) and simple sugars, and low vitamin D levels, has been linked to an increased risk of autoimmune diseases, including MS. Repair of myelin sheaths, critical for nerve cell function, occurs mainly in the early stages of MS, highlighting the importance of nutritional prophylaxis and preventive measures.
The Role of Diet in Managing MS
Given the potential impact of diet on MS, several dietary patterns have been proposed to mitigate the course of the disease. These include well-established diets with proven health benefits, such as the Mediterranean diet, anti-inflammatory diets, the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, ketogenic diets, intermittent fasting (IF), and gluten-free diets. Additionally, specific diets developed exclusively for MS, such as the Wahls, McDougall, and Swank diets, have also been studied.
A well-balanced diet can also counteract malnutrition, which can occur as a patient's mobility decreases.
Read also: Managing Weight Loss with MS
Dietary Patterns and Their Impact on MS
Mediterranean Diet
The Mediterranean diet, based on traditional foods from the Mediterranean region, includes a high intake of vegetables, fruits, nuts, beans, cereals, grains, fish, and unsaturated fats like olive oil. Moderate red wine consumption is also sometimes recommended. While research specifically on MS and Mediterranean diets is limited, the available evidence suggests it may not directly affect the course of MS. However, its general health benefits make it a worthwhile consideration.
The MIND diet, a hybrid of the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets, focuses on foods known to benefit brain health. It emphasizes green leafy vegetables, other vegetables, nuts, berries, beans and legumes, whole grains, fish, white meat poultry, avocado, and extra virgin olive oil. The MIND diet promotes plant-based meals with five to six servings of fruits and vegetables daily, providing fiber for gut health. It also encourages the consumption of unsaturated fats and moderation in dairy intake. Research suggests the MIND diet protects brain tissue from further damage in people with MS and may improve cognition.
Anti-Inflammatory Diets
Since MS is an inflammatory autoimmune disease, anti-inflammatory diets aim to reduce inflammation in the body. These diets typically emphasize foods rich in antioxidants, such as fruits, vegetables, and healthy fats like omega-3 fatty acids.
Ketogenic Diet
The ketogenic diet is a high-fat, very low-carbohydrate diet that forces the body to use fat for energy instead of glucose. This metabolic state, called ketosis, has shown promise in various experimental models, including animal studies demonstrating reduced inflammatory mediators.
A pilot study suggested that a modified ketogenic diet might benefit patients with MS by alleviating fatigue and depressive symptoms, reducing body fat, and decreasing pro-inflammatory adipokines. A larger study involving patients with relapsing-remitting MS (RRMS) reported significant improvements in disability status, quality of life, fatigue, and body fat levels after a 6-month ketogenic diet intervention. Another pilot study found that a ketogenic, isocaloric diet based on Mediterranean diet principles and rich in medium-chain triglycerides (MCTs) led to increased lean body mass, improved metabolic profile (reduced inflammation), and increased satiety in MS patients.
Read also: MS and Nutrition
One theory supporting the use of the ketogenic diet in MS involves its impact on the gut microbiota, increasing gut microbial diversity. Studies have shown that a ketogenic diet can increase the concentrations of significant microbial groups in MS patients, potentially normalizing their gut microbiota composition compared to healthy individuals.
However, ketogenic diets don't provide all the vitamins and minerals we need, without supplements. Serious problems are rare, but the way the body gets energy from keto diets could lead to problems with the pancreas and liver. If you cut down on carbohydrates, your diet will be lower in fibre too. We need fibre for a healthy gut and to avoid constipation.
Intermittent Fasting (IF)
Intermittent fasting involves cycling between periods of eating and voluntary fasting on a regular schedule. Studies suggest that IF has an immunomodulatory effect, potentially mediated by the gut microbiome.
Animal studies have shown that IF can alter the composition of the microbiota, enriching beneficial bacterial families and decreasing interleukin 17-producing T cells (IL-17) while increasing Treg cells in the gut-associated lymphoid tissue (GALT). A clinical trial examining the effects of intermittent fasting and a calorie-restricted diet in MS patients found that both approaches were unlikely to be harmful for short-term weight loss. These diets were also associated with trends toward improved cardiometabolic outcomes and emotional well-being.
Gluten-Free Diet
A gluten-free diet eliminates gluten, a protein found in wheat, barley, and rye. While not directly linked to MS, some individuals with MS may experience gluten sensitivity or celiac disease, making a gluten-free diet beneficial.
Read also: MS and the Mediterranean Diet: A Connection?
Paleo Diet
Paleo diets are based on foods that are thought to have been common in the Paleolithic era, before humans started farming. So they include meats, fish, nuts, vegetables and fruit. The idea is that our bodies are best adapted to eating these kinds of foods.
A recently published study found that a paleo diet may be useful in the treatment of MS, reducing perceived fatigue, improving mental and physical quality of life, increasing exercise capacity, and improving arm and leg function.
Following a Paleo diet wouldn’t generally be considered bad for you, although you’d have to make sure you were getting all the nutrients you need. Cutting out cereals and dairy could mean you miss out on some B vitamins, vitamin D and calcium. And if you have high energy needs or you’re underweight, excluded foods might make it harder to get the energy you need.
Wahls Diet
The Wahls diet is based on a Paleo diet, and it’s part of what’s called the Wahls Protocol. This combines the diet with vitamins, meditation, and exercise. There are also newer versions of the Wahls diet, including a ketogenic (keto) diet. One small but well-designed research study suggests a Wahls diet might help with fatigue.
The Wahls diet, a modified paleo diet, emphasizes a high intake of fruits and vegetables, particularly green leafy vegetables, sulfur-rich vegetables, and intensely colored produce. It also encourages the consumption of seaweed, algae, and nutritional yeast while limiting gluten-free grains, legumes, and eggs. According to a 2021 analysis, the diet is effective in reducing symptoms of fatigue and improving quality of life in MS.
The Wahls elimination diet, a stricter version, avoids all grains, legumes, nightshades, and dairy, while allowing unlimited saturated fat consumption. A study found that the Wahls elimination diet was associated with increased quality of life and decreased fatigue, as well as improved anxiety and depression scores.
Swank Diet
The Swank diet, developed by Dr. Roy Swank, is based on the observation that MS incidence is higher in areas with higher saturated fat intake. It is very low in saturated fat (up to 15 g per day), fatty meat, and processed foods. A recent study suggests the Swank diet might help with fatigue.
McDougall Diet
The McDougall diet is a very low-fat diet (10% of energy from fat, 14% from protein, 76% from carbohydrates) consisting mainly of plant-based starchy foods, vegetables, and fruits. Animal products, including eggs, dairy products and oils are not allowed.
Overcoming MS (OMS) Diet
The OMS diet program does not allow the consumption of meat, poultry, eggs, dairy, coconut oil or palm oil, but recommends a plant-based diet of whole foods and seafood.
The Gut-Brain Axis and MS
The gut-brain axis, a bidirectional communication system between the CNS and the gastrointestinal system, plays a crucial role in MS. The gut microbiota, a key component of this axis, influences the innate immune system. Dysbiosis, an imbalance in the gut microbiota, has been linked to MS pathogenesis.
Diet significantly impacts the composition and metabolism of gut microbiota. A diet high in fat, sugar, and animal protein can promote the growth of pathogenic bacteria, leading to enteric inflammation and damage to the intestinal barrier. Conversely, a diet rich in vegetables, fiber, probiotics, and vitamins can promote gut eubiosis, increasing microbial diversity and anti-inflammatory mediators like short-chain fatty acids (SCFAs).
Specific Nutrients and Their Role in MS
Antioxidants
Oxidative stress contributes significantly to MS. Dietary antioxidant factors can dampen oxidative stress and may help against chronic demyelination and neuronal or axonal damage. Antioxidant factors such as curcumin, vitamin D, and fatty acids have been studied and seem to play a role in the regulation of oxidative stress.
Vitamin D
MS patients frequently exhibit vitamin D deficiency. Low levels of vitamin D are associated with a higher risk for the development and relapse of MS. Supplementation with vitamin D has been shown to have anti-inflammatory and immunomodulatory effects on MS pathogenetic mechanisms by inhibiting the production of CD4+ T cells, thus lowering the risk of MS and diminishing disease progression.
Fatty Acids
Fatty acids, especially omega-3 polyunsaturated fatty acids (PUFAs), are associated with ameliorating neurodegeneration in MS. Intake of PUFAs consumed via fish, nuts, and seeds seems to be associated with protective effects against demyelination. In animal models, PUFAs decrease inflammation, maintain immunomodulation and promote neuroprotection and remyelination.
Lifestyle Changes for Managing MS
In addition to dietary modifications, lifestyle changes can significantly impact MS symptoms and disease progression.
Exercise
Exercise can provide important improvements in walking, balance, cognition, fatigue, depression, and quality of life for people with MS. Moderate-intensity aerobic activity and strength training exercises are recommended.
Stress Management
Stress can exacerbate MS symptoms. Stress management techniques, such as mindfulness, gratitude, and positive self-talk, can help manage stress and improve overall well-being.
Sleep Hygiene
Adequate sleep is crucial for managing MS. Establishing good sleep habits, such as putting down screens before bedtime, exercising daily, controlling caffeine intake, and avoiding alcohol and nicotine, can improve sleep quality.
Foods to Include in an MS-Friendly Diet:
- Fruits and vegetables: all fresh fruits and vegetables
- Grains: all grains, such as oats, rice, and quinoa
- Nuts and seeds: all nuts and seeds
- Fish: all fish, especially fresh fish and fatty oily fish, such as salmon and mackerel, as they’re high in omega-3 fatty acids and vitamin D
- Meats: all fresh meats, such as beef, chicken, lamb, and more, especially beef liver, which is particularly high in vitamin D and biotin
- Eggs: good source of biotin, vitamin D, and other important nutrients
- Dairy products: such as milk, cheese, yogurt, and butter
- Fats: healthy fats, such as olive, flax seed, coconut, and avocado oils
- Probiotic-rich foods: such as yogurt, kefir, sauerkraut, and kimchi
- Beverages: water, herbal teas
- Herbs and spices: all fresh herbs and spices
Foods to Limit or Avoid in an MS-Friendly Diet:
- Processed meats: sausages, bacon, canned meats, and meats that are salted, smoked, or cured
- Refined carbs: white bread, pasta, biscuits, and flour tortillas
- Fried foods: french fries, fried chicken, mozzarella sticks, and doughnuts
- Highly processed foods: fast food, potato chips, and convenience and frozen meals
- Trans fats: margarine, shortening, and partially hydrogenated vegetable oils
- Sugar-sweetened beverages: energy and sports drinks, soda, and sweet tea
- Alcohol: limit consumption of all alcoholic beverages as much as possible
Practical Tips for Managing Diet with MS
- Plan your meals: Planning meals in advance can help you save energy later.
- Rearrange your kitchen: Place food, utensils, and other equipment in easy-to-reach areas.
- Try "ready-to-use" items: Buying precut fruits and veggies can save time and simplify cooking.
- Make thicker drinks: If you have difficulty swallowing, prepare thicker beverages like smoothies.
- Choose soft foods: If chewing is tiring, opt for softer foods like baked fish, bananas, and cooked veggies.
- Limit crumbly foods: If you have difficulty swallowing or choking, limit foods that crumble.
- Reach out for help: Ask for help with meal preparation, cleaning, or setting the table.
- Stay active: Exercise is important for overall health and weight management.