COMMENTARY

How to Incorporate Diet Into Multiple Sclerosis Care

Stephen Krieger, MD; Ilana Katz Sand, MD

Disclosures

May 31, 2022

This transcript has been edited for clarity.

Stephen Krieger, MD: Hello, everyone. I'm Dr Stephen Krieger, a professor of neurology at the Corine Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai in New York.

Ilana Katz Sand, MD: Hi. I'm Dr Ilana Katz Sand, an associate professor of neurology, also at the Corine Goldsmith Dickinson Center for Multiple Sclerosis.

Krieger: Dr Katz Sand and I are going to talk about new research in diet and nutrition in multiple sclerosis (MS), a big topic that our patients commonly ask us about. There's now emerging science and data to help guide our nutritional and diet conversations with our patients.

Dr Katz Sand, can you start by telling us a little bit about the state of the science in diet and nutrition research in MIS?

Katz Sand: Sure. I agree that this is a super important topic. It's something our patients ask us about all the time. That's actually what inspired me to start working in this space.

It's been a long road, but I think we are finally starting to make some progress. There have been a number of studies published over the past few years that have given us small insights. A bunch of different pilot studies have been used, including one that we published on some different dietary patterns and how those potentially can have an impact on MS symptoms, as well as some observational studies. Then there's our work recently presented at the American Academy of Neurology (AAN) meeting.

Krieger: Diet is notoriously difficult to study in such a way that produces robust and reproducible results and outcomes. For a long time in the field of MS there were diets for which we lacked data to support them. But now we definitely have some.

Returning to your work in diet and nutrition in MS, can you tell us about the results you presented at the AAN meeting in Seattle in April 2022?

Katz Sand: We've been interested in looking at Mediterranean-type diets for some time now. One reason for that is the generalizability of these diets. If people are able to incorporate them, that's good for their general health, which makes it a good pattern to look at. There's very good research at this point establishing general health benefits of this type of diet.

It's also something that the whole household can do. It's good for everyone. We ran a pilot study a few years ago looking at the feasibility of studying this pattern in clinical trials. Adherence was excellent. People didn't find it too difficult to do. It doesn't require any specialized foods to buy. It's budget friendly.

We also published a paper last year showing a connection between the Mediterranean-DASH Diet Intervention for Neurodegenerative Delay (MIND) diet score and MRI outcomes. Specifically, there we were looking at thalamic volume in people with early MS. We saw an association between thalamic volume and the MIND score, which was really interesting to see in people very early on in their disease course. We were inspired to focus in on that pattern.

A Study Design to Help Understand the Value of the Mediterranean Diet in MS

Katz Sand: The work that we presented at AAN was an observational study looking at our clinic population. We used our neuropsychiatric clinic, where we refer all our patients for a comprehensive annual assessment. It's a wonderful program for patients and clinicians. It allows for a more detailed perspective than just the clinical visit and the MRI, but instead really doing some higher challenge tasks for people, asking them to fill out surveys. This gives us access to a bunch of different outcomes that we can then measure.

We embedded within that the Mediterranean Diet Adherence Screener (MEDAS), a 14-item diet scale that assigns a 0 or 1 for each item depending on whether people meet the threshold. There are questions about consumption of olive oil, fruits and vegetables, nuts. Then on the flip side of that, questions about butter, pastries, sugary beverages, etc. After responding to those questions, you end up with a score.

We ultimately looked at a sample of 563 people. We had this score done on everyone who came to the clinic. This meant that we didn't introduce biases about who volunteered or didn't volunteer for a study. That's really helpful because we were capturing not only data on diet but also on lifestyle and many other factors.

We looked at how that diet data associates with the outcomes that we collected. Our major disability outcome was the Multiple Sclerosis Functional Composite (MSFC), which comprises the nine-hole peg test, the timed 25-foot walk, and the Symbol Digit Modality Test. That allows us to get a nice look at sensory, motor, and cognitive functioning, both as a composite and separately.

Then we also looked at a bunch of patient-reported outcomes secondarily. We looked at fatigue, mood, and the Multiple Sclerosis Impact Scale, which gives an overall look at how symptoms affect daily life.

Because these are people who came through our clinic and we knew we were going to be focused not only on diet but also on other factors and looking at prognosis over time, we collected a lot of really detailed demographic and health information. We collected information on age, sex, body mass index. We developed a composite index for socioeconomic status that we paid really careful attention to, including a neighborhood deprivation index. We collected information on smoking, hypertension, high cholesterol, diabetes, exercise — just a ton of different factors.

After we controlled for all of these factors, what we found was a very robust association between their Mediterranean diet score and their level of disability. MSFC was our primary outcome, but the association was also significant for all of the patient-reported outcomes that we looked at. Very interestingly, this withstood correction for multiple comparisons.

We also reran the MSFC analysis for disability after putting fatigue and mood into the model, thinking that might affect people's performance. It did, but the association was still there and still pretty robust. Those are the main findings.

Krieger: You found an association here between both measurable disability and patient-reported outcomes, indicating that the more they adhere to this Mediterranean-style diet and stay away from some of the bad nutritional actors you mentioned — butter, processed food, sugar — the more favorable those scores were.

Katz Sand: Yes, exactly. Now, this is a cross-sectional study. It's a single timepoint. It's an observational study. So, of course, the conclusions are limited, because we need to look at how people do over time and to do interventional studies. But we thought it was pretty powerful stuff in terms of an observation.

Conversely, as I noted, the big advantages to this study are that we had an objective outcome measure. We had everyone fill out the survey, so we didn't have issues with biases, dropouts, and things like that. And we collected in a very robust way a lot of demographic and health-related information for covariates. Yet even when you do that, there's always potential for unmeasured confounders.

An Interventional Analysis of the Ketogenic Diet in MS

Krieger: You mentioned that the Mediterranean-style diet is an achievable one. It's something that families can all get on board with. It's a generally health-positive diet. There are other diets that are being studied in MS, including the ketogenic diet, which also had a presentation at the AAN meeting. Can you summarize the results of that study and what they were looking at?

Katz Sand: Dr Nicholas Brenton and colleagues gave a presentation on ketogenic diet in relapsing MS. His group ran an interventional study of about 65 people with MS who volunteered to follow a ketogenic diet for 6 months. The study was really interesting and they did a really nice job with it. It's an open-label study, so of course there are limitations there in terms of interpretation.

But they were able to show that 83% of patients were able to adhere to the diet throughout the study. They measured adherence in an objective way by having people use strips to test their urine for ketone bodies. That was great, as adherence is a really hard thing to assess in diet studies.

The people who followed the diet had great outcomes, such as reductions in their body weight and fat mass. They had positive changes in terms of their adipokine balance, with their leptin going down and adiponectin going up. And they had good effects on fatigue and mood, which are really important in people with MS. There seemed to also be an effect on some of the disability outcomes. I think it's really interesting work.

Krieger: Your own study, in a very large and broad cross-section of MS patients, shows those sorts of benefits with a Mediterranean-style diet. It's interesting to combine that with this study, which features a much more restrictive diet and different recommended food groups: very low in carbohydrates but high in fat and protein. It may be difficult for people to adhere to the ketogenic diet for the long term, and it might be challenging for families to all get on board with that kind of diet at the same time.

But I think in the aggregate, there is definitely a signal here and opportunity to study this in future interventional, and even potentially randomized, trials. That would allow us to get more-definitive answers about what is the optimal diet, if there is one, and how that can be achieved for people with MS.

Katz Sand: In our study we found these associations. In their study, they did an intervention and found positive outcomes. Even though it's an uncontrolled study, I think it's still important and contributes to the literature. But I think the takeaway is that diet is a potentially really powerful tool that we can use.

Yes, we've made great progress in disease-modifying therapies, but they're not perfect. Our patients with MS have ongoing issues symptomatically and from a neurodegenerative standpoint, even if we control their inflammation. So we should really be looking at everything that we can to set people up for success. This is one of a number of tools that we should be looking to harness.

Where to Start When Discussing Diet With Your Patients

Krieger: How do you use this with your patients? What do you tell people nowadays — the low-hanging fruit that they can do to optimize diet in MS?

Katz Sand: What I tell people is that we don't necessarily have specific evidence from any of the interventional trials that have been done, because they've all been similar to this ketogenic study we've just talked about, with small, pilot-like designs. We don't have specific evidence to say this particular diet is going to be a disease modifier and is going to definitely help your prognosis in MS.

But I think what our observational study — as well as other, previous studies — have taught us and we can pass along to our patients is that there are certain changes that everyone can make that are going to be helpful. Whether it's going to have a specific effect on prognosis, we're not entirely sure yet. But you are going to feel better and these things are good for your general health anyway. So, I think they're reasonable to try.

I emphasize with my patients that if there's just one thing they do, it's try to reduce your reliance on processed foods as much as possible. When you look at all the different diets that are under study, that's something that's common to most of them: taking out the processed foods and adding in more things that are fresh. That's something that I really encourage people to work on.

We also have really good research in MS showing that having diabetes or high cholesterol, or being overweight, is associated with worse prognosis. Anything that you can do to help avoid those complications is clearly going to be a benefit. That's kind of where I try to steer people at the moment.

Krieger: In general, I think you are perhaps a little bit stronger with your patients about their dietary choices than I am with mine. But every time I talk to you about it, I learn a little something and move a little bit more in your direction.

The balance I try to strike with my patients is that I don't want them to have to think about having MS all the time. And I don't want them to have to deprive themselves of things that genuinely bring them pleasure. But at the same time, as you said, taking care of MS is a long-term process. We're trying to optimize brain health for their years and decades to come. Keeping them away from processed foods is a good way to start that process.

Katz Sand: What you just said is actually very consistent with everything that I've said. That's what I love about the Mediterranean pattern: It's not a diet; it's a lifestyle. It's just a way of approaching food. Once you get into it and incorporate these principles into your life, it becomes part of what you do.

It's not, "Oh, I can have this" or "I can't have that." It's actually very easy to find foods that are enjoyable for everyone. You don't necessarily have to say, "This is a no and this is a yes." There are not a lot of rules, really. It's just general guiding principles people can incorporate.

I tell people that the reward is that you feel better. When we ran our pilot study, that was one of the things that people told me when the study was ending. They said, "Because the study was over, I went out and I ate this, this, and this. And I felt so terrible the next day that I actually went right back to following the study protocol because I realized that I felt so much better on it."

Krieger: That's great. I like what you said and I'm going to use it, which is that it's not a diet; it's a lifestyle. You're advocating not just a Mediterranean diet but living a Mediterranean lifestyle. I think we could all get behind that in the MS community.

Dr Katz Sand, thank you so much for sharing your work and your insights on diet. And on behalf of Medscape, I'm Stephen Krieger at Mount Sinai in New York.

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