Diet - factsheet
Date of issue: March 2008
Introduction
For many people with MS, managing what they eat offers the possibility of a sense of control in dealing with MS. Taking personal control of a fluctuating, unpredictable condition can be very important. Control of diet also offers the opportunity to promote general health and wellbeing, which may be even more important following a diagnosis of MS.
This factsheet summarises and reviews evidence about diet in MS, and is intended for those looking for general information. However, it does not constitute medical advice. If you are in any doubt, please discuss this with your MS nurse or GP, or ask for a referral to a Registered Dietitian.
We would like to thank Bernice Chiswell, Registered Dietitian at Bedford General Hospital and the Beds and Northants MS Therapy Centre for her help in producing this factsheet.
Contents
- Comparison with general population
- Is diet a factor in developing MS?
- What is a good diet for MS?
- Elements of a balanced diet
- Fruit and vegetables
- Carbohydrates
- Fats
- Proteins
- Dairy products
- Other dietary concerns
- Vitamin D and calcium
- Other vitamins and minerals
- Fluids
- Specific diets for MS
- Swank Diet
- Best Bet Diet
- Points to consider
- Supplements
- Further reading
- References
1. Comparison with general population
A diagnosis of MS does not mean that someone has nutritional difficulties. One research study showed that the majority of people who are newly diagnosed or who have only mild MS symptoms had a comparable level of overall nutritional health with the general population.[1]
However, some people with MS may be more susceptible to complications arising from poor diets. Weight gain and obesity may become unwanted side effects of limited mobility or of some medications. Similar problems can be caused by excessive dependence on convenience foods if fatigue is a major problem. By contrast, some people with MS may experience significant weight loss, perhaps through problems in preparing food or from the side effects of some medications that act as appetite suppressants.
Poor diet and nutrition can also worsen existing symptoms such as fatigue and weakness. Fatigue can be a particular problem as a few heavy meals can make this much worse; frequent, small meals may be more manageable.
If you are overweight, underweight or have unwanted weight loss/gain, ask your GP for an appointment with a dietitian. It is important that any dietary changes you make will not be detrimental to health. Avoid 'crash dieting' or excluding food groups to lose weight.
2. Is diet a factor in developing MS?
Studies of where MS occurs (epidemiology) have shown that the risk of MS is higher in countries where there is a high consumption of animal fat. However, studies of the population as a whole in these countries have not shown that eating a diet high in saturated fat causes someone to develop MS. Conversely, no study has found that eating more fruit and vegetables protects against developing MS. Consequently, the link between animal fat intake and developing MS has not been proven.[2]
Recent research has suggested a link between inadequate levels of vitamin D and the risk of developing multiple sclerosis. Lack of exposure to sunlight and/or inadequate dietary intake of vitamin D in childhood increase the likelihood that someone may develop MS in later life. There is no consensus about whether increasing vitamin D intake once MS has developed makes any difference to the course of an individual's MS.[3]
3. What is a good diet for MS?
Research into diet and MS has been limited. Diet is notoriously difficult to research, for a number of reasons:
- it is usually impossible for researchers to control exactly what someone else eats over a period of time
- it is often very difficult to contrast an 'active' element with a 'dummy' placebo
- what someone eats is known and obvious, so there cannot be any 'blinding', as there would be in a drug trial
- most research is expensive and costs need to be recouped. Many foods are cheap, so there is little financial benefit in proving them beneficial
However, there has been research into a healthy diet for other conditions, notably cardiovascular disease, which is much more common than MS in the general population. This research found that a diet that was low in fat, with lots of fruit and vegetables reduced someone's risk of developing heart disease, strokes and certain cancers. Consequently it forms the Government's advice for a normal balanced diet.
4. Elements of a balanced diet
See the website www.eatwell.gov.uk for more information.
A balanced diet is essential to provide all the nutrients needed to be as active and healthy as possible. A balanced diet needs to include foods from the major food groups of fruit and vegetables, carbohydrates, fats, protein and dairy products. Each of these is considered in turn.
Fruit and vegetables
Fruit and vegetables provide a range of vitamins and minerals. The current recommended daily intake is five portions a day, a portion being, for example, an apple, a small glass of fruit juice, two plums or three tablespoons of cooked vegetables. Fruit and vegetables are a vital source of antioxidant vitamins, which are important in helping to maintain and protect myelin. Fruit and vegetables are also an important source of soluble fibre, which can help proper bowel function.
Carbohydrates
Carbohydrate is vital for producing slow-release sugars, which provide energy, and is found in starchy foods such as bread, cereals, potatoes, pasta and rice. It is recommended that carbohydrates should make up around a third of the daily diet. High fibre carbohydrates such as whole grain cereals, wholemeal or fibre fortified white bread etc, can help prevent and treat constipation.
Fats
Fat is a vital element in any diet because it contains concentrated calories or energy. Some types of fat provide essential fatty acids, which are required for the human body to function properly. These cannot be made by the body and therefore have to be consumed in the diet.
There are two kinds of fats: saturated fats, found in meat and animal fats (e.g. lard) and dairy products such as butter and cheese; and unsaturated fats, which are divided into monounsaturated fats, such as olive oil, and polyunsaturated fats such as sunflower oil.
Research has shown a link between a high saturated fat intake and an increased risk of heart disease and certain cancers, suggesting that a diet that reduces saturated fat intake is desirable. Monounsaturated fats are better for the heart than saturated fats, but do not have any proven benefits for MS.
Some polyunsaturated fats have been found beneficial for people with multiple sclerosis. Polyunsaturated fats are made of two kinds of essential fatty acids, omega 3 essential fatty acids and omega 6 essential fatty acids. It is important to achieve a balance between these two groups, so it is recommended for health that foods from each are included in the diet.
Omega 3 essential fatty acids are present in oily fish such as salmon and mackerel, which are also good sources of protein and vitamin D. Other sources include green leafy vegetables and linseed oil. Omega 3 essential fatty acids are important as part of a balanced diet, but the main benefit for MS has been found with omega 6 essential fatty acids.
The main omega 6 essential fatty acid is linoleic acid. This is found in the oils of seeds and nuts, such as sunflower, safflower, soya, corn seeds or walnut oils. A combined analysis of three small controlled trials into linoleic acid indicated that taking 17-23g linoleic acid a day, via spreads or oils, could benefit some people with relapsing/remitting MS. There was a reduction in the number and severity of relapses, particularly for those who were newly diagnosed or more mildly affected. In terms of increase in disability, less or no benefit was shown in people who had more symptoms at the start of the trials. However, those who were newly diagnosed or had minimal disability at the start of the trial seemed to stabilise, with little decrease in ability over the two and a half years of the trial when compared to the control group. There is no evidence that increasing linoleic acid benefits people with progressive MS as insufficient numbers were included in the trial.[5]
Based on this research, the NICE Guideline for the Clinical Management of MS recommends linoleic acid for people with relapsing/ remitting MS.[6]
Read the Linoleic Acid factsheet
Protein
Protein is vital to enable the body to build and maintain amino acids, the fundamental building blocks of the human body. Protein is present in meat, fish, beans and cheese among other foods. The Government recommends two portions of protein a day. Foods containing protein can also be a source of saturated fats.
Dairy products
Dairy products including milk, cheese, yoghurt and cream are a good source of calcium and vitamins A, B12 and D. All full fat dairy products are a source of saturated fat, and rich in calories. Therefore, low fat products are a healthier substitute, particularly if weight gain is an issue. Conversely, for people with low weight, full fat products can be a useful way of consuming more calories easily.
5. Other dietary concerns
Vitamin D, calcium and osteoporosis
People with MS have been shown to be at a higher risk of osteoporosis, a condition of the bones which mean they are more prone to fractures than normal, or of osteopenia, a reduction in bone density or mass.[7,8] Factors that increase the risk include difficulties in mobility and weight bearing, long-term exposure to corticosteroids – often used to treat MS relapse – and, in women, when post-menopausal, as the hormone oestrogen is known to protect against osteoporosis.
Osteoporosis tends to be under-recognised and under-diagnosed, so it is important to ensure that regular screening is requested from your GP if you have any of the risk factors listed above. Bone density needs to be measured by, for example, DEXA scan. However, provision of these scans varies considerably across the UK and waiting times can be very long.
Osteoporosis is also associated with an inadequate intake of vitamin D and calcium (see below). Vitamin D is manufactured by the skin when it is exposed to sunlight. However, heat sensitivity and living in the UK may mean that many people with MS do not get enough exposure to sunlight to gain their vitamin D in this way. Vitamin D is also found in oily fish such as salmon and mackerel, and in dairy products.
Calcium is another vital mineral for building and maintaining healthy bones. It is mainly found in dairy products, with some in green leafy vegetables such as broccoli and cabbage. If dairy products are avoided, calcium fortified soya products can increase the amount of protein and calcium in the diet, as well as adding variety. Additionally, a range of vitamins and minerals are present in many vitamin fortified breakfast cereals.
Other vitamins and minerals
Various research studies have examined possible relationships between other vitamins and minerals and MS. It is beyond the scope of this factsheet to consider all this research, but the MS Trust Information Service is happy to investigate the published literature in response to enquiries about specific vitamins and minerals.
Fluids
Adequate fluid intake is essential to prevent dehydration. Too little fluid can increase the risk of urine infections, tiredness, headaches, constipation, and thus worsen existing MS symptoms. Recommended guidelines are one and a half litres or eight glasses of fluid a day. Caffeinated drinks such as tea, coffee, cola and caffeine fortified soft drinks are best consumed in moderation, eg no more than four mugs of coffee a day, as caffeine can irritate the bladder. The same is true of alcoholic drinks.
Read the Bladder Problems factsheet
Read the Bowel Problems factsheet
6. Specific diets for MS
Many diets are promoted in terms of managing or even improving MS. The majority of these diets are exclusion diets. Exclusion diets suggest that you stop eating one or several groups of foods, or that some foods are not combined with other foods. Those who recommend some exclusion diets state that food allergies are common in MS; there has not been any research that upholds this theory. If a food allergy is suspected, your GP should be able to refer you to an NHS allergy clinic, although waiting times for these can be long.
Two of the most widely-known diets are:
Swank diet
In 1948, Dr Roy Swank began treating people with MS on a very low fat diet, because of the apparent association between dietary fat and MS. Results were reported in 1970 and again in 1990. 144 people were followed for up to 34 years, with good results reported in the long-term level of disability. Those people who adhered strictly to the diet and were experiencing mild symptoms when they started had slower disability progression than those who had not adhered strictly to the diet.[9]
However, there are problems with this trial. It did not conform to modern expectations, in that there was no comparison group and there was no 'dummy' treatment. It is possible that people who did not continue with the diet perceived no benefit from it because they were deteriorating, so we cannot know whether the good results represent a genuine improvement over other groups of people with MS or were a lucky chance.
Best Bet Diet
The Best Bet Diet is a strict exclusion diet developed by Ashton Embry. It is based on the hypothesis that MS is caused by intact food proteins escaping from a leaky gut, which causes the immune system to malfunction. There have not been any clinical trials of this diet, and results have not been published in any peer-reviewed journal. Anecdotal reports from people with MS suggest that the Best Bet Diet works for some people but does not work for others. There are concerns about how easy it is to achieve a balance of all the food groups whilst following this diet. The diet recommends consuming large quantities of supplements, which can be expensive and which is not necessary with a normal balanced diet.
Points to consider for any MS-specific diet
Any diet can be difficult to follow, and, before embarking on one, it is worth considering these points:
- have you been given balanced or evidence-based information about the diet, or does it only seem to be promoted by enthusiasts?
- will the diet be worse than the symptoms that it might alleviate – eg will it stop you eating all the foods you enjoy, or make going out for meals / meals with family or friends difficult?
- does it make realistic claims for improvements in MS?
- will your diet still be balanced?
- how affordable is it?
- will cooking/preparing it be a problem?
7. Supplements
Dietitians consider that a balanced diet should contain the full range of normal vitamins and minerals for healthy living. Supplements in themselves cannot replace a balanced diet. When taking large doses of supplements it is also possible to overdose on some vitamins, which may be harmful. If you are concerned about a specific deficiency, consult your GP or ask for a referral to a Registered Dietitian.
8. Further reading
- Bowling A.
Complementary and alternative medicine and multiple sclerosis.
New York: Demos Medical Publishing; 2007. - Payne A.
Nutrition and diet in the clinical management of multiple sclerosis.
Journal of Human Nutrition and Dietetics 2001; 14: 349-357. - Schwarz S, Lewling H.
Multiple sclerosis and nutrition.
Multiple Sclerosis 2005; 11:24-32.
9. References
- Thomas FJ, Wiles CM.
Dysphagia and nutritional status in multiple sclerosis.
Journal of Neurology 1999; 246: 677-82.
abstract - Schwarz S, Lewling H.
Multiple sclerosis and nutrition.
Multiple Sclerosis 2005; 11: 24-32.
abstract - Munger KL, Zhang SM, O'Reilly E et al.
Vitamin D intake and incidence of multiple sclerosis.
Neurology 2004; 62: 60-5.
abstract - Broadley SA.
Could vitamin D be the answer to multiple sclerosis?
Multiple Sclerosis 2007; 13(7): 825-826. - Dworkin RH, Bates D, Millar JH et al.
Linoleic acid in multiple sclerosis: a reanalysis of three double-blind trials.
Neurology 1984; 34: 1441-5.
abstract - National Institute for Clinical Excellence.
Multiple sclerosis: understanding NICE guidance – information for people with multiple sclerosis, their families and carers, and the public.
London: NICE; 2003. - Nieves J, Cosman F, Herbert J et al.
High prevalence of vitamin D deficiency and reduced bone mass in multiple sclerosis.
Neurology 1994; 44: 1687-92.
abstract - Cosman F, Nieves J, Komar L et al.
Fracture history and bone loss in patients with MS.
Neurology 1998; 51: 1161-5.
abstract - Swank RL, Dugan B.
Effects of low saturated fat diet in early and late cases of multiple sclerosis.
Lancet 1990; 336(8709): 37-9.
abstract