A reasonable approach to diet

Allen Bowling and Thomas Stewart, Rocky Mountain MS Center, Colorado
Adapted with permission

Open Door - February 2006 pages 8-9

Whether it is possible to influence MS through diet and dietary supplements is a controversial topic. Some sources, especially those written by mainstream MS professionals, refute the connection, often stating something like "there is no evidence of any benefit." Other sources suggest that MS can effectively be cured by such strategies. Both views are overstated, and the conflicting information is unhelpful to people trying to make decisions about how to live with MS.

Dietary guidelines are recommended to the general population as a way to reduce the risk of conditions such as cancer and heart disease. Whilst it is clearly a good idea for people with MS to follow these guidelines, the benefits are the same as for people without MS. In other words, although it is important to have a varied diet that is rich in fruits, vegetables and whole grains, it isn't clear that such an approach will improve the course of MS.

For those who prefer to use only absolutely proven treatments, then there's no diet or supplement to use. For those interested in low risk, possibly effective approaches, then a few of the well studied options are described below. These dietary approaches should be used in addition to, rather than instead of, proven licensed medications.

The best studied strategies relate to different kinds of dietary fats.

n-3 fatty acids

The most suggestive studies relate to n-3 or omega-3 fatty acids, or, more specifically, to EPA (eicosapentanoic acid) and DHA (docosahexanoic acid). Although no single study of n-3 fatty acids conclusively demonstrates a favourable effect, the body of evidence is quite suggestive.

n-3 fatty acids cause changes in the immune system that would theoretically be useful in people with MS. Population studies suggest that MS is less common in countries where intake of n-3 fatty acids is relatively high.

Specifically, there is a well-designed study in which those taking n-3 fatty acids in the form of fish oil had less disability progression than those taking a dummy placebo. Unfortunately, the difference between the groups was in a range that might have occurred due to chance alone. A second well-designed study showed a similar benefit, but was too small to be conclusive.

n-6 fatty acids

n-6 or omega-6 fatty acid is found in sunflower oil, corn oil and sunflower oil. Three small studies have examined whether n-6 fatty acids may be beneficial in MS but the results are mixed. In two studies, those supplementing with sunflower oil had less severe relapses than those taking a placebo. However, no effect on relapse frequency or disability progression was observed.

Another study reanalysed the evidence and concluded that supplementation with sunflower oil helped to slow disability progression, but only among those with little or no disability. Serious flaws in the way the data was analysed make it difficult to draw strong conclusions from this study.

Saturated fats

Saturated fats are found in meats and dairy products. General advice is to lower intake to less than 10% of total calories to decrease the risk of heart disease. No well-designed clinical trial has been conducted to determine whether decreased saturated fat improves outcomes in MS. However, there are some population studies suggesting a decreased risk of MS in areas where people consume less saturated fat.

A long-lasting but poorly designed study by Dr Roy Swank suggests that decreasing saturated fat improves outcomes in MS. This study is provided as justification for the low fat 'Swank diet'.

Vitamin D and calcium

Vitamin D has never been studied among people with MS in a direct way. However, in a large survey, those who supplemented with vitamin D seemed less likely to develop MS than those who did not.

Population studies note that the incidence of MS seems to increase with distance from the equator. Some have speculated that this may be explained by exposure to sunlight - an important factor in determining vitamin D levels.

Both calcium and vitamin D are important to prevent osteoporosis, which is relatively common among people with MS.

Other supplements

Studies of supplements are sparse, so it is difficult to know whether they are helpful or harmful. However, as cells of the immune system can cause damage in MS, it makes sense to avoid immune-stimulating supplements, such as ginseng and echinacea, especially in high doses or for extended periods of time. Other risks, including potential toxicities, drug interactions, and interactions with other underlying health problems mean it is always a good idea to discuss all supplements with your health professionals.

MS relevant dietary strategies

Based on the above, the following strategies may be considered.

Increase intake of fats that are rich in n-3 fatty acids, such as EPA, DHA and ALA (alphalinolenic acid). Sources of n-3 fatty acids include: oily fish (especially salmon, herring, mackerel, sardine and cod) - the richest sources of EPA and DHA oils from certain seeds and nuts (primarily flaxseed and walnut). The n-3 fatty acid found in these oils (ALA) is probably less potent than the EPA and DHA found in fish. However, this may be the better option for strict vegetarians supplementary sources of EPA and DHA include fish oil, salmon oil and cod liver oil. Sources of ALA include flax seed oil and walnut oil. Sometimes labels indicating ALA will in fact refer to alpha-lipoic acid, which is not relevant here. Make sure the product has alpha-linolenic acid. Studies of EPA and DHA in MS have used between 1 and 3 grams obtained from between 3 and 10 grams of fish oil daily - amounts that would be difficult to obtain from dietary sources alone. Up to 3 grams of combined EPA and DHA is considered safe.
Maintain or modestly increase your intake of n-6 fatty acids. Because the average diet is relatively high in n-6 fatty acids and low in n-3 fatty acids, the most reasonable strategy may be to increase n-3 intake.
If you increase the relative amounts of n-3 and n-6 fatty acid in your diet, then it is important to supplement with modest amounts of vitamin E (100 IU daily). This may be obtained from a vitamin E supplement or a multi-vitamin. Vitamin E is found in soya, corn and olive oil, nuts and seeds, and wheatgerm.
Decrease intake of saturated fat.
Consider increasing vitamin D and calcium. The Food Standards Agency (FSA) suggests that taking 25 micrograms (0.025 mg) or less of vitamin D supplements and 1500 mg or less of calcium supplements a day is unlikely to cause any harm. Determining how much elemental calcium is in supplements is sometimes difficult, so it is important to read the label carefully.
Avoid supplements that boost the immune system.

References

MS relevant CAM Information:

www.ms-cam.org
interactive CAM website of Rocky Mountain MS Center.
Bowling AC.
Alternative Medicine and Multiple Sclerosis.
New York: Demos Medical Publishing, 2001.
Bowling AC, Stewart TM.
Current complementary and alternative therapies of multiple sclerosis.
Current Treatment Options in Neurology 2003;5:55-68.
Bowling AC, Stewart TM.
Dietary Supplements and Multiple Sclerosis: A Health Professional's Guide.
New York: Demos Medical Publishing, 2004.
Swank RL.
Multiple sclerosis: fat-oil relationship.
Nutrition 1991;7(5):368-376.
Bates D, Cartlidge NE, French JM, et al.
A double-blind controlled trial of long chain n-3 polyunsaturated fatty acids in the treatment of multiple sclerosis.
Journal of Neurology Neurosurgery & Psychiatry 1989;52(1):18-22.
Dworkin RH, Bates D, Millar JH, Paty DW.
Linoleic acid and multiple sclerosis: a reanalysis of three double-blind trials.
Neurology 1984;34(11):1441-1445.
Paty DW.
Double-blind trial of linoleic acid in multiple sclerosis.
Archives of Neurology 1983;40(11):693-694;
also reported as: Paty DW, Cousin HK, Read S, Adlakha K.
Linoleic acid in multiple sclerosis: failure to show any therapeutic benefit.
Acta Neurologica Scandinavica 1978;58(1):53-58.
Bates D, Fawcett PR, Shaw DA, Weightman D.
Polyunsaturated fatty acids in treatment of acute remitting multiple sclerosis.
BMJ 1978;2(6149):1390-1391. (The "Bates n-6 Trial.")
Millar JH, Zilkha KJ, Langman MJ, et al.
Double-blind trial of linoleate supplementation of the diet in multiple sclerosis.
BMJ 1973;1(5856):765-768.

General CAM Information:

Spencer JW, Jacobs JJ
Complementary/Alternative Medicine: An Evidence-Based Approach.
Mosby, 1999. (Technical)
Kraft GH, Catanzaro M
Living with Multiple Sclerosis: A Wellness Approach.
Demos Medical Publishing, 2000.
Jellin JM, Batz F, Hitchens K
Natural Medicines Comprehensive Database.
Therapeutic Research Faculty, 2002. (Technical) (www.NaturalDatabase.com)

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