Download MS Society. Diet And Nutrition

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Third edition
May 2008
11
MS
Essentials
For people living with MS
This publication is available in large print (22 point) and audio CD
Call 020 8438 0799 or email [email protected]
Diet and
nutrition
Like everyone else, people with MS can benefit from a
healthy diet. It’s also an aspect of life which you can control
and adjust to suit you and your needs. This booklet explains
what is meant by a ‘well-balanced diet’, why we should all
be aiming for one and how to get one.
You might find that symptoms of MS affect what you can
eat or how you prepare meals. Learning new ways of cooking,
or using energy-saving tips can help you carry on eating what
you enjoy. Adjusting to MS will not always mean changing your
diet, but sometimes it can help.
Contents
02 A well-balanced diet
06 Practical suggestions
for a balanced diet
08 Practical solutions for
preparing food
10 Managing your weight
11 Diet and your MS
14 Research into diet
and MS
15 Essential fatty acids
and MS
17 Vitamins, minerals
and MS
18 The Swank and
Best Bet diets
20 Caring for the dietary
needs of people more
severely affected by MS
22 Further information
Many special diets have been proposed as treatments, but
none have been proven to prevent MS or affect the way it may
develop. Special diets are best approached with caution as
some may be expensive or even harmful. Most people do not
need to use expensive supplements either. You can usually
get the nutrients you need through your daily meals.
With careful planning, perhaps with the help of a dietitian,
you can make sure you meet your dietary needs – even if they
change over time. Many people with MS report that they feel
better when they eat well.
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A wellbalanced diet
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The benefits of a well-balanced diet
Eating nutritionally balanced meals helps the body work to its
full potential, which is particularly important for people living
with long-term, unpredictable conditions like MS.
The effects of MS vary from person to person and can change
from one day to the next. Many people find they can improve
their quality of life and sense of well-being by focusing on
aspects of health that can be controlled and changed – such
as diet. This, combined with appropriate exercise, can help:
•
control weight
•
decrease fatigue
•
maintain regular bowel and bladder function
•
minimise the risk of skin problems
•
keep bones healthy and strong
•
maintain healthy teeth and gums
•
strengthen the heart
•
improve muscle strength and range of motion
•
increase flexibility
What makes up a healthy, balanced diet?
Diet and nutrition © MS Society 12/09
It is now widely recognised that a healthy diet contains a balance
of the major food groups:
2
•
Proteins – for growth and tissue repair.
•
Carbohydrates and sugars – for energy.
•
Fats – to absorb certain vitamins and for essential
fatty acids.
•
Fibre – for healthy digestion.
•
Vitamins and minerals – for numerous processes in the body,
including tissue repair, bone strength and the absorption of
other nutrients.
•
Fluids – for optimum working of the body. Water carries nutrients
around the body and is used in the various chemical processes
happening in our cells.
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These food groups contain nutrients with specific roles and a lack
of any of these may cause health problems directly, or affect how
other nutrients are absorbed by the body. For example, a lack of
calcium can cause bone weakness, but even if there is enough
calcium in the diet, a lack of vitamin D can slow the absorption of
calcium and also lead to bone weakness. This is why it is important
that there is a balance of all these food groups in your diet.
The diagram below shows the proportions generally recommended
to balance these food groups and get the nutrients we need.
Fruit and vegetables: ‘five-a-day’
Eating five portions of fruit or vegetables per day is widely
recommended. Frozen, dried, fresh and tinned fruit and vegetables
all count, but the five portions need to be varied, as different fruits
and vegetables contain different nutrients. It is wise to include
some fresh produce in the five portions, as levels of certain
vitamins, including vitamin C, are lower when tinned or dried.
Starchy vegetables, eaten mainly for carbohydrates, like potatoes,
do not usually count towards the five portions per day. One
portion might be two or three heaped tablespoons of spinach,
an apple or a glass of fruit juice (150ml). However, because juice
has less fibre than the whole fruit, it can only count as one portion
per day, however much you drink. With smaller fruits, like apricots
or plums, two fruits make up a portion.
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The Food Standards Agency website (www.eatwell.gov.uk) has
further details.
Can supplements help, or be used instead of fruit and
vegetables?
Vitamins and minerals have a number of vital functions in
the body. Certain drug treatments can lower levels of vitamins
and minerals in the body and a doctor or dietitian may suggest
supplements to replenish these. But a balanced diet usually
provides a sufficient supply of vitamins and minerals for most
people. There is no evidence that high doses benefit people
with MS. Excess vitamins and minerals can sometimes be harmful.
Some studies have suggested that eating fruit and vegetables
has greater health benefits than taking vitamin and mineral
supplements. This may be because the benefits of fruit and
vegetables are not just from the individual components, called
‘phytochemicals’, but also from the interactions between these
components.1 On top of this, eating fruit and vegetables is a
healthy way to get fibre and carbohydrates.
Vegetarian and vegan diets
Vegetarian and vegan diets may need more careful planning to
ensure they cover all essential nutrients, but a dietitian can help
you find alternatives. The Vegetarian Society and Vegan Society
can also provide information.
Treats
Diet and nutrition © MS Society 12/09
Remember that there is no harm in the occasional treat that is
high in saturated fat, sugars or salt. You needn’t feel guilty for
enjoying a chocolate bar or packet of crisps every now and then.
And some treats can be healthy. Strawberries, for instance, are
full of vitamins and zinc, even if they do have a little cream poured
over them. Eating out at restaurants can also be a good way to
try new things – and can give you new ideas to try out at home.
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Food allergy and intolerance
Research does not support the use of gluten-free or other diets
excluding specific foods to treat MS.3 However, just like anyone
else, people with MS can react to particular foods. If you think
you may have an intolerance or allergy, your doctor or dietitian
can help you look into it further. Reliable testing for food allergy
or intolerance involves following a properly supervised exclusion
diet. As this process can be time-consuming, inconvenient and
costly, it is worth considering the pros and cons: will following the
diet be worse than the symptoms it could alleviate? Will you still
be able to have a balanced diet and maintain a healthy weight?
How would such a diet impact on finances, shopping, cooking,
family meals and meals out?
Adapting to a new diet and new techniques
The effects of MS vary greatly and you may never experience
some of the symptoms or problems mentioned in this booklet.
But changes to your circumstances might affect the foods
you choose and your nutritional needs. Because everyone has
different experiences, culture and lifestyle, how each person
adapts will vary.
Food is more than just a necessity. It can also be a social activity,
so any changes to your diet need to be realistic and suited to
your lifestyle as well as your dietary needs. Be ready to try new
things – if you choose healthy food that you like, it might be
easier to stick to any changes you make.
Dental hygiene
Some MS symptoms can have an impact on dental hygiene, so
it is important to have regular check ups with your dentist. Tremor
and fatigue, for example, might both make brushing your teeth
more difficult. Certain drugs used to treat MS symptoms can
cause a dry mouth, which might also affect the health of your
teeth and gums. Your dentist may recommend a mouthwash or
fluoride gel to help avoid problems and can give advice on the
easiest ways to brush effectively. See the MS Society factsheet
Oral health for more information.
Diet and nutrition © MS Society 12/09
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Practical suggestions for a balanced diet
Suggestion
Nutrition
Five portions of fruit or
vegetables every day including
one portion of dark green, leafy
vegetables
•
Use polyunsaturated margarines
and oils such as sunflower oil or
corn oil, instead of saturated fat
such as lard and butter.
Grill, bake, steam or poach food
instead of frying.
Diet and nutrition © MS Society 12/09
Health benefits
Fruit and vegetables are good sources of vitamins,
minerals and fibre.
• Dark green, leafy vegetables also contain a small amount
of an omega 3 essential fatty acid (EFA).
•
•
Sunflower oil and corn oil are polyunsaturated fats which
are also good sources of the omega 6 EFAs.
•
•
Omega 6 EFAs are important for a healthy nervous system.
Polyunsaturates can lower blood cholesterol levels and therefore help reduce
the risk of heart disease.
•
Frying foods often means using more fat. It is better to
use these lower-fat cooking options.
•
Cutting down saturated fats can reduce the risk of heart disease.
• Meat is rich in iron, zinc, B vitamins and protein.
Choose lean cuts of meat.
Sausages, pâtés and beefburgers
are often high in saturated fat.
6
a diet matches these proportions can be difficult. Planning a flexible menu for the week can be
a balanced diet:1,2
When liquid vegetable oil is turned into solid fat – through
a process called hydrogenation – harmful ‘trans fats’ can
be formed. Like saturated fat, trans fats can raise blood
cholesterol levels.
Vitamins and minerals have many benefits, including working as antioxidants and
helping the body use other nutrients.
• Fibre helps keep the digestive system healthy.
• Omega 3 EFAs are important for a healthy nervous system, heart and circulation.
Iron helps the blood to carry oxygen around the body.
Zinc is important for healing and repair and allows the body to use carbohydrates,
fat and proteins effectively.
• B vitamins have a variety of uses: for a healthy nervous system, to release energy
from our food and to help blood carry oxygen around the body.
• Protein is needed for the body to repair and heal itself.
•
•
Avoid too much saturated fat
and hydrogenated vegetable oil
in foods like pastry, cakes and
chocolate.
•
Eat at least two portions of fish
a week, one of which should be
oily fish like mackerel, pilchards,
salmon or sardines.
Use low-fat dairy products such
as skimmed milk, low-fat yoghurt
or low fat cheeses.
•
Eat wholemeal bread and
wholegrain cereals.
•
•
•
A low-fat source of carbohydrates.
High in B vitamins and vitamin E.
High in fibre.
•
•
•
Drink six to eight cups of fluid
daily (about two litres). Don’t rely
on high-caffeine drinks, such
as coffee, tea and cola.
•
Water is needed for the body to function.
•
•
•
•
Cutting down on saturated and hydrogenated fats can reduce the risk of heart disease.
•
Fish is a good source of protein, vitamins and minerals,
such as selenium and iodine.
• Oily fish is rich in omega 3 EFA and vitamins A and D.
•
•
•
•
•
•
Omega 3 EFAs are important for a healthy nervous system, heart and circulation.
Vitamin A is good for the skin and eyes.
Vitamin D helps keep bones and teeth healthy.
Selenium plays a role in a healthy immune system and acts as an antioxidant.
Iodine helps produce important hormones for a healthy metabolism.
White fish is particularly low in fat.
Dairy products are a good source of protein, calcium and
vitamins A, B12, and D.
• Lower fat alternatives have slightly lower levels of vitamins A
and D, but the same levels of the other nutrients as full fat.
•
•
•
•
Protein is needed for the body to repair and heal itself.
Calcium and vitamin D are needed for strong bones and teeth.
Vitamin A is good for the skin and eyes.
Vitamin B12 is important for a healthy nervous system.
Carbohydrates are a vital source of energy.
Vitamin E has many functions, including as an antioxidant.
B vitamins have a variety of uses: for a healthy nervous system, to release energy
from our food and to help blood carry oxygen around the body.
• Fibre helps keep the digestive system healthy.
A good fluid intake can help keep the bladder and bowels healthy.
Caffeine and alcohol can make the body more dehydrated.
Dehydration can affect memory, concentration and energy levels.
Diet and nutrition © MS Society 12/09
Of course, our eating habits don’t neatly fit into diagrams or lists of food groups, and judging whether
helpful, and by following some simple principles of healthy eating, you can be confident you are getting
7
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Practical
solutions for
preparing
food
Page 8
Living with MS can mean that regular tasks like shopping and
preparing food take longer or need more careful planning. For
example, fatigue can make shopping trips over-tiring, or tremor
could make chopping vegetables difficult. An occupational therapist
(OT) can suggest energy-saving tips and helpful equipment or
adaptations. They can also advise on grants that may be available
for adaptations. Social care services (social work in Scotland)
can arrange for an OT assessment to see if equipment would
be helpful. Your GP can refer you to an OT for help with energy
saving tips, or managing particular symptoms. For more information
on adaptations, see the MS Society publication Adaptations and
your home.
Shopping
There are many grocery delivery services available, including
online shopping, which can save a trip round the supermarket
or high street, and avoids carrying heavy shopping home.
A health care ‘assessment of need’ from the social care services
(social work in Scotland) department of your local authority
could entitle you to help getting your shopping.
Diet and nutrition © MS Society 12/09
Techniques for preparing foods
8
•
To avoid moving around the kitchen unnecessarily, why not
gather all the ingredients together before you start to cook? Some
people prefer to use a table in the kitchen to eat at, rather than
carry meals to another room. If balance is a problem, grab rails
can be fitted to many kitchen units and walls.
•
Cooking with a microwave means there are no heavy
pans to lift.
•
Some tasks can be done just as well sitting as standing.
Overhanging worktops can often be fitted to kitchens to make
this easier. Height-adjustable stools and stools with sloping
seats (perching stools) can make getting up and down less tiring.
•
Dishwashers can make cleaning less tiring, but may not be the
best option for all as they still need to be filled and emptied.
•
If heat makes symptoms worse, microwaves can help as they
don’t warm the kitchen while cooking. Induction hotplates also
warm the pans without heating the air around them.
•
If you live with others, sharing tasks can make preparing meals
easier and quicker, and cooking together can be fun.
•
Cook a double batch, freeze the spare one, and use on a day
when you don’t have the time or the inclination to cook something.
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Pre-prepared foods
•
If preparing food is difficult or tiring, ready meals can be a good
solution. However, they are sometimes high in fat and salt and
not nutritionally balanced, so may not be suitable for every day.
Dietitians can advise on easy-to-prepare alternatives or ways
to supplement your diet if you rely greatly on ready meals.
•
Meals on wheels deliver ready-prepared meals to your door.
Many areas offer this service as part of a care package from social
services. To find out if you are eligible, contact your council’s
social services (social work in Scotland) department. They will do
an assessment to see what your needs are. Caterers can usually
meet special requirements on health or religious grounds.
•
If you have trouble preparing a cooked meal, you may be eligible
for Disability Living Allowance. For more information, see the
MS Society publication Claiming Disability Living Allowance.
Practical equipment
There are gadgets and tools to help with almost every daily task
in the kitchen. The following list gives an idea of what is available
and organisations like the Disabled Living Foundation, Ricability
and the RNIB can provide further information.
If grip is difficult or dexterity affected:
•
jar and ring-pull openers
•
easy-grip handles on cutlery, peelers and other utensils
•
tap turners – large handles to fit over existing taps
•
knob turner – adaptable gadget that fits many different shapes
and sizes to help with fiddly controls
•
two-handed cups
•
non-slip chopping boards
If lifting heavy items is difficult:
•
cooking baskets – let you lift food in and out of pans,
rather than lifting a heavy pan of boiling water
•
a wheeled trolley – to move ingredients, pans and prepared
food more easily
•
kettle tipper – lets you pour a kettle without lifting it
If you have visual problems:
•
large controls and displays on cookers, microwaves,
timers and weighing scales
•
speaking weighing scales
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Managing
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•
coloured tape around worktops can help provide a contrasting
edge
•
brightly coloured chopping boards, cutlery and utensils also
contrast better with surfaces and make items easier to spot
in drawers
Both weight loss and weight gain can be a problem for people
with MS, but this can be managed and controlled by tailoring a
‘personal diet plan’. A dietitian can help you develop a plan that
adjusts as your needs change, ensuring you always get a healthy
balance of nutrients. It is not always easy to stick to a rigid plan,
so keep it flexible and remember that occasional treats are not
forbidden. Remember also that weight problems may not be directly
linked to your MS. Your doctor or other health care professional
can investigate the problem to find the cause.
Weight loss
If someone is underweight they may become malnourished and
weak, which can make MS symptoms like fatigue, muscle weakness
or spasms worse.4
There are many reasons people with MS might not eat as much
as they need. Problems with posture, swallowing, fatigue and
tremor can all make shopping for, preparing or eating food more
difficult. Appetite can also be affected by stress, anxiety and
depression, as well as certain drug treatments. You should approach
your doctor if you have concerns about any of these issues.
Because early signs of malnutrition, like fatigue and muscle
weakness, can also be symptoms of MS, the problem may initially
go unnoticed. But your doctor or dietitian can help investigate
and treat the underlying causes of your weight loss.
If getting enough energy and nutrients is difficult, over-the-counter
or prescription supplements may be useful. If you use high-energy
foods and drinks, remember that they often have high sugar
content, so early, preventative dental care is important.
Diet and nutrition © MS Society 12/09
Weight gain
10
Keeping generally fit and healthy can make it easier to cope
with the symptoms of MS. But having MS may mean you are less
active than you once were, so you might find you put on weight.
Appropriate exercise and a healthy, balanced diet can help you
return to your natural weight, but there may be additional things
you can do to help lose weight.
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For example, to keep up a good intake of liquids, some people
rely on fruit juices or sugary drinks. Switching to water or low-sugar
versions could cut down the calories without risking dehydration.
Sugary and fatty snacks are sometimes ‘comfort food’ at times of
stress and worry. Occasional snacking like this should be no great
cause for concern, but if you are comfort eating a lot and think you
may be depressed, discuss this with your doctor as depression
can be treated.
Some drug treatments, including steroids used for acute relapses,
can also cause weight gain.
You may not experience the symptoms and effects of MS that
follow, but if you do, you might find that certain changes to what,
and how, you eat may help with managing them.
There is more information in the MS Society publications
Managing the bowel in MS, Managing bladder problems,
Swallowing difficulties, Fatigue, Tremor and Vision and MS.
Bladder problems
Some people with bladder problems drink less to reduce their
need to go to the toilet. However, this can mean you have more
concentrated urine, which can irritate the bladder and increase
the chances of getting urinary tract infections. Drinking six to eight
cups (about two litres) of water per day is generally recommended.
It is best to avoid large quantities of caffeine and alcohol as these
might irritate the bladder.
There is no conclusive evidence that cranberry juice in particular
helps to prevent or treat urinary tract infections. NICE, the
organisation which assesses treatments in England, Wales and
Northern Ireland, does not recommend the regular use of cranberry
juice to prevent infections.5
Review papers (reports which assess the overall evidence of
several scientific studies) have looked at cranberry juice for
preventing and for treating urinary tract infections. The authors
concluded that there was not enough evidence to show that
cranberry can treat infections.6 It might help to prevent urinary
tract infections in young and middle-aged women, but it’s not
clear how much someone would need to drink. There is very
little evidence for cranberry for men, younger or older women,
or people with MS in particular.7, 8, 9 And it’s worth noting that
drinking large amounts of any fruit juice can cause unwanted
weight gain as they are high in sugar.
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Diet and
your MS
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Bowel problems
Dietary changes are often suggested as the first line of treatment
for people with MS who experience constipation.5 Good fluid
intake can help regular bowel function, as can a diet with plenty
of insoluble fibre. This is fibre that cannot be digested and passes
straight through the gut, helping digestion of other foods and
removal of waste. A well-balanced diet, with plenty of fruit and
vegetables can provide this fibre. Prunes (or prune juice), figs,
wholemeal bread, fibre-fortified white bread, brown rice and
wholegrain breakfast cereals are particularly good sources
of insoluble fibre. More information on good sources of fibre
can be found at www.eatwell.gov.uk
Swallowing problems – dysphagia
Diet and nutrition © MS Society 12/09
Not everyone experiences changes in swallowing, and for some
who do, changes are so small they are hardly aware of them. But
difficulties with swallowing – or dysphagia – can be a distressing
symptom, especially if not managed properly. There are a number
of ways to modify your eating habits or diet that can help:
12
•
If chewing is difficult, try to avoid tough or stringy food.
•
If big meals are a problem, small, frequent meals and milky drinks
can help to ensure you get enough calories.
•
A change in your seating position may make swallowing easier.
•
Soften food with a fork or blender to minimise chewing and make
swallowing easier.
•
If swallowing is weak, thin fluids like water or tea can go down
the wrong way, causing discomfort and a potential choking
hazard. Using thickening agents in drinks can help and are
available on prescription.
•
Some people find it harder to drink enough fluid through the day
when drinks have been thickened. To avoid dehydration, sip little
and often. Pre-thickened fruit juices, also available on prescription,
may be more appetising and they are always the right consistency.
•
If swallowing difficulties are causing weight loss, nutritional
supplements might be helpful.
These ways of eating and drinking might also help if you experience
facial pain (trigeminal neuralgia), which can make opening the
mouth and chewing difficult.
A speech and language therapist (SLT) can advise on swallowing
problems. Ask for a referral through your GP or MS nurse.
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Fatigue
Fatigue can sometimes be helped by adjusting the diet. For those
who get tired quickly, eating large, hot meals can be difficult,
so smaller, more frequent snacks may be better. It can also be
a good idea to include starchy carbohydrates, like potatoes and
bread, in meals throughout the day, as this can help keep energy
levels up. Relying too much on sugary foods for energy can make
fatigue worse, as they cause energy peaks followed by lows.
Dehydration can lead to tiredness, so aim to drink six to eight
cups (about two litres) of fluids per day. Drinks that contain a lot
of caffeine, such as tea, coffee and cola can have a pick-me-up
effect initially, but too much caffeine can dehydrate you.
Tremor
Tremor can affect your nutritional needs or your approach to
eating. Constant tremor uses up calories, so high-energy foods
and drinks between meals might be necessary to avoid weight
loss or worsening fatigue.
If tremor affects holding or reaching for things, certain foods may
be easier to eat than others. A sandwich, for example, is easier
to manage than spaghetti or soup. Specially designed cutlery,
crockery and kitchen utensils, can make the preparation and
eating of food more manageable.
Visual problems
Double-vision or blurring may make preparing or eating food more
time consuming and may seem to limit choice. However, there are
practical solutions that can help. These are outlined on pages 9
and 10.
Maintaining bone health
Osteoporosis causes bones to become fragile and more at risk of
breaking. Several factors might increase the risk of osteoporosis
for people with MS:
•
Extensive use of steroids to treat relapses.10
•
A lack of weight-bearing exercise, for example, for those who
are less mobile.10
•
Avoiding sunlight because of heat sensitivity or fatigue, leading
to lower vitamin D intake.11
To help reduce this risk, it is important to keep up good levels
of both vitamin D and calcium in the diet, as these both help
keep bones strong and healthy.
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Good sources of vitamin D include oily fish, liver and eggs.
Excessive doses of vitamin D supplements might be harmful.2
Milk and dairy products are the richest sources of calcium,
but tinned sardines and pilchards (where the bones are eaten),
sultanas, bread, spinach and red kidney beans are also good
sources. Skimmed milk contains as much calcium as full-fat
milk, so cutting down on fat need not mean losing out on calcium.
Calcium-enriched soya products offer a non-dairy alternative.
If you do not get much exposure to sunlight, or you are prescribed
a course of steroids, a doctor or dietitian may suggest
supplements to prevent a deficiency, but it is possible to get
sufficient calcium and vitamin D through your diet and sunlight.
Pressure sores
If someone lies or sits in one position for even short periods, there
is a risk of pressure sores developing. Losing too much weight
can add to this risk, if you lose the natural padding over bony
points.12 A dietitian can help you monitor and maintain a healthy
weight to avoid this.
See the MS Society factsheet Pressure sores for more information.
Research into
diet and MS
There has not been a great deal of research into diet and MS,13
which can be frustrating.
Diet and nutrition © MS Society 12/09
Effective studies into diet can be difficult to design and control
compared with laboratory trials into drug treatments. To be
confident in a trial, researchers have to account for anything that
may affect the results. For example, if a new drug is given to a group
of people on a trial, researchers need to know if any of them are
already taking other drug treatments. If they are, this could explain
unusual results. However, because diet is part of people’s everyday
lives, and people eat many different types of food, it is almost
impossible to ensure everyone involved in the trial eats exactly the
same thing, over a long period of time. This makes it very difficult
to closely monitor particular foods and draw definite conclusions
from the research.
14
Research does not show that someone’s diet causes MS.14 Neither
have any special diets been proven to prevent MS or affect the way
it may develop.11 Research has not found high doses of any vitamins
or minerals to be of benefit either.3 Some experts feel that although
the evidence is not conclusive, diets low in saturated fats and high
in polyunsaturated fats may have therapeutic effects on MS.3
More research is needed to see if polyunsaturated fats can have any
definite effect. In the following sections we take a look more closely
at polyunsaturated fats and at two specific diets low in saturated fats.
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It is important to note that a healthy, balanced diet will usually
provide you with appropriate levels of nutrients. High doses of
certain vitamins and minerals should be avoided as they may
do more harm than good.2
One aspect of MS research that has received a lot of interest
in recent years is the role of fats and oils, also known as ‘lipids’.
There are three main forms of lipids in our diet: saturated,
monounsaturated and polyunsaturated. Lipids are a source of
energy and they store certain vitamins. They have received particular
attention in MS research because they also have a role in the
central nervous system (the brain and spinal cord). This is where
damage occurs in MS.
In particular, some think that omega 6 linoleic acid – an ‘essential
fatty acid’ – may benefit some people with MS. NICE, the
organisation which assesses treatments in England, Wales and
Northern Ireland, advises that 17-23g per day of linoleic acid may
help slow down the disabling effects of MS.5 Health professionals
do not all agree that this is the case, but there is no doubt that
linoleic acid is a valuable part of a healthy diet.
The ways in which essential fatty acids affect the central nervous
system are complex and not yet fully understood. But part of the
story may be their immunosuppressive and anti-inflammatory
effects, as the table on page 16 explains.
A good balance of EFAs
It is unclear exactly how omega 6 and omega 3 interact and the
relative advantages of each. Both play an important part in a healthy
nervous system, but to be broken down and used effectively they
have to compete for the same chemicals in the body. Too much
of either might limit the effects of the other, and the best levels
needed for each EFA are not yet clear. A good balance of both
omega 6 and omega 3 may be more important for people with
MS than the total amounts of each. Further research is needed
to identify the ideal intake.10 A balanced diet as recommended
on pages 6 and 7 should provide healthy amounts of both.
Diet and nutrition © MS Society 12/09
Essential fatty
acids and MS
15
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Polyunsaturated fats and essential fatty acids
Diet and nutrition © MS Society 12/09
Polyunsaturated fats are made of what are known as essential fatty acids (EFAs).
These cannot be made in the body and are a natural part of a healthy diet. EFAs are
needed to make and repair myelin – the protective sheath around nerve fibres that is
damaged in MS. There are two main groups of EFAs: omega 6 (which contains acids
in the ‘linoleic family’) and omega 3 (which contains acids in the ‘alpha-linolenic family’).
16
Omega 6 EFAs
Omega 3 EFAs
Including
• linoleic acid (LA)
• gamma-linolenic acid (GLA)
• arachidonic acid (AA)
Including
• alpha-linolenic acid (ALA)
• eicosapentaenoic acid (EPA)
• docosahexaenoic acid (DHA)
Common dietary sources
• seeds
• legumes (peas, lentils and beans),
• sunflower, safflower, evening
primrose and corn oils
Common dietary sources
• oily fish
• certain nuts and seeds
• a small amount in dark green
vegetables
Necessary for
• the structure of cell membranes
• the production of Prostaglandin E2
(PGE2) – one of the hormone-like
substances called eicosanoids
that help regulate inflammatory
and immune responses
Necessary for
• the structure of cell membranes
• the production of Prostaglandin E3
(PGE3) – one of the hormone-like
substances called eicosanoids
that help regulate inflammatory
and immune responses
Prostaglandin E2
Prostaglandin E3
Prostaglandin E2 (PGE2) appears to
have an immunosuppressive effect
– that is, it reduces the activity of the
immune system. This may be beneficial
for people with MS, as MS is an
autoimmune condition, where the
immune system, which normally fights
infection, instead becomes overactive
and attacks the protective myelin sheath
around nerve fibres. This is why some
people suggest that raised levels of
PGE2 can benefit people with MS.10
Prostaglandin E3 (PGE3) is thought
to have anti-inflammatory properties.
In theory, this could help people
with MS because inflammation in
the central nervous system is one
of the processes that occurs in MS.10
However, no significant benefits have
been reported from published trials.11
Vitamins,
minerals
and MS
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Vitamins and minerals have a number of vital functions and have
complex relationships with each other. Some are needed so that
the body can use other nutrients effectively – for example zinc
and vitamin B6 are both needed in the diet if you are to benefit
from omega 6 and omega 3 essential fatty acids.10 Others, like
vitamins A, C and E, can work as ‘antioxidants’.
Antioxidants
Oxidants, or free radicals, are chemicals that react easily with other
substances in the body, changing or damaging their structure. For
example, essential fatty acids are vulnerable to attack from oxidants.
Certain vitamins can limit the damage oxidants cause and protect
the essential fatty acids. These vitamins are known as antioxidants.
Finding antioxidant-rich foods is easy. Look for brightly coloured
fruits and vegetables – red, orange, green and yellow – and include
four to six servings a day.
Some research has suggested that oxidant activity in the central
nervous system may be linked to the damage that occurs in MS.
However, there have been few studies into the use of antioxidants
for people with MS and the significance of oxidants is still unclear.15
Antioxidant therapy might also carry a risk for people with MS,
as some antioxidants have a stimulating effect on the immune
system, which in theory could worsen the effects of MS. Further
research is needed to determine the safety and potential benefits
of antioxidant therapy for MS.3,11,16
Vitamin B12
The exact relationship between MS, MS treatments and vitamin
B12 is complex and not yet fully understood.17
Vitamin B12 is needed for the body to make myelin – the protective
layer around nerve fibres that gets damaged in MS. Because of the
importance of vitamin B12 in the nervous system, and because
a deficiency can lead to symptoms similar to those found in MS,
some people have suggested it can help treat or prevent MS.
However, research does not support these theories.11,16
Most people with MS have normal vitamin B12 levels, but
deficiencies can arise. Your doctor can check if this is a problem
and provide appropriate treatment if necessary.
Vitamin D
We get vitamin D through our diet and by exposure to sunlight.
Some people have suggested that low levels of exposure to
the sun could increase the chances of developing MS.
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This is because MS is more common in areas further from the
equator – areas where there is less intense sunshine and people
may therefore get less vitamin D. However, there may be other
explanations for these geographical differences. Further research
is needed to understand the relationship between exposure
to sunlight and MS.
However, because vitamin D can help reduce the risk of
osteoporosis, sufficient intake is important. This is particularly
true for those who are less mobile or have taken long courses
of steroids.
Recent research has, for the first time, shown that a lack of
vitamin D early in childhood or before birth may increase the risk
of developing MS later in life.18 More work needs to be done to
prove the theory and to see if there are other environmental factors
that may affect MS.19 It is good health advice that everyone
(whether you have MS or not) should get the recommended daily
amount of essential vitamins and nutrients. If you can, spending
a healthy amount of time outside is a sensible course of action
as vitamin D is produced by exposure to sunlight. This, together
with a balanced diet that contains plenty of oily fish, should mean
you’ll get all the vitamin D you need. If you are considering taking
supplements ask a health care professional for advice.
See the MS Society Vitamin D research factsheet for more
information, available on the Research pages of the MS Society
website or by calling the Information Team.
The Swank
and Best
Bet diets
Over the years, there have been many specific diets promoted as
effective therapies for MS. Although individuals sometimes report
positive results from following a particular diet, none have been
proven effective for people with MS in general.
Some diets are restrictive and potentially harmful to someone’s
overall health – if vital nutrients are excluded or drastically reduced
– so it is sensible to check out any new diet with a dietitian or
your doctor.
Diet and nutrition © MS Society 12/09
Restrictive diets suggested to treat MS include allergen-free,
gluten-free, pectin-restricted, low-sugar and diets that avoid
processed foods. What we currently understand about MS does
not suggest these food types need to be generally avoided.3
18
Here, we look briefly at two well-known diets sometimes promoted
for people with MS: the Swank Diet and the Best Bet Diet.
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The Swank Diet
The ‘Swank Diet’ is perhaps the best known diet associated with
MS. It increases the amount of polyunsaturated fatty acids eaten
and reduces the amount of saturated fats. Saturated fat is cut to
15 grams or less per day and, as well as recommending fish, the
diet adds vegetable oil and cod-liver oil every day.
The Swank Diet is named after Dr Roy Swank, who developed
the diet in the 1940s. The largest research trial of his diet had
a number of shortcomings and research has not shown definite
benefits from this particular regime. However, following this or
a similar diet would not generally be considered bad for health.
Cutting down on meat and dairy foods to reduce saturated
fats might leave a shortfall in protein, so it’s important to find
alternative sources such as fish, beans and pulses. Cod-liver
oil has a blood-thinning effect and should be taken with caution
if you take aspirin, anti-coagulant medications (for example,
warfarin) or have a bleeding disorder. If you are diabetic you
should also speak to your doctor before taking cod-liver oil.3
This diet can be low in energy and unless care is taken to maintain
energy intake, it may not be suitable if you have high energy
needs or are underweight.
The Best Bet Diet
The Best Bet Diet also receives considerable attention in the
press. It is based partly on the assumption that MS is caused and
worsened by a leaky gut, and that dietary changes can strengthen
the gut, the barrier between the blood circulation and the central
nervous system (the ‘blood-brain barrier’), and the immune system.
The body of scientific evidence to date does not suggest that
MS is caused or worsened by a ‘leaky gut’.
The Best Bet Diet recommends avoiding several different food
types, including all dairy, grains and red meat. Fish, chicken and
turkey are recommended for protein. It also recommends having
allergy tests to discover other foods to be avoided and includes
a list of 18 recommended supplements.20
Currently, research does not suggest there would be benefits for
MS from taking large numbers of supplements or from cutting out
any of these food types completely. It’s also worth remembering
that taking supplements comes with a financial cost. Like the
Swank Diet, this diet can also be low in energy so care should
be taken if you have a high energy need or are underweight.
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Caring for the
dietary needs
of people
more severely
affected by MS
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Some people more severely affected by MS can find food and fluid
intake difficult. They may be unable to prepare meals, buy food
or plan a balanced diet. Carers – sometimes family or friends –
may become more involved and might want to consult specialist
health care professionals to ensure they are meeting the dietary
needs of the person they care for. Professional advice can benefit
everyone – getting a healthy balanced diet is valuable for carers
too. There is a list of useful recipe books at the back of the
booklet.
Likes and dislikes
Whatever someone’s needs or restrictions when eating and
drinking, they will have favourite foods and foods they would
rather avoid. Religious, cultural and personal tastes should all
be taken into account with any changes that need to be made.
Making changes to a diet can mean having to cook new foods,
or prepare them in new ways. A ‘likes and dislikes’ list can help
make meals enjoyable as well as nourishing. A dietitian can
help with this, ensuring the list of ‘likes’ is broad enough to keep
things interesting as well as healthy, accommodating tastes and
preferences as much as possible. A perfectly balanced diet is
no use if it is left uneaten!
Planning for the week
It is not uncommon for someone to have a number of carers,
possibly a mix of professionals, friends or family. If several people
assist with food it can help to monitor meals prepared, to be sure
there is a good overall balance. Agreeing a weekly plan is one
way to do this.
Shopping lists can be tailored to the weekly plan, avoiding food
going to waste and unnecessary trips to the shops. Also, getting
together to plan the week’s food lets everyone have an input,
even if they do not visit the shops themselves. Internet shopping
is another way to choose groceries from home.
Diet and nutrition © MS Society 12/09
Keeping the plan flexible allows for the changes and surprises that
can happen in daily life. The idea is to plan for a healthy, balanced
diet, rather than regiment an everyday activity.
20
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Make food and drink accessible
It can be handy to have a selection of food and drinks available
and easily accessible night and day. A secure, clean place to
store food and drink near the bedside, for example, can save
unnecessary trips to the kitchen – and is especially helpful if
eating regular small meals or sipping drinks.
Some people with severe visual problems find it helpful if food
is set out in an agreed way. For example, laying out the different
parts of a meal as if the plate were a clock face makes it easier
to choose which foods to eat – potatoes might be placed at
‘12 o’clock’ and meat at ‘6 o’clock’.21
Chewing and swallowing – PEG feeding
If someone has great difficulty chewing or swallowing their food,
and softening food, thickening drinks and eating smaller meals
doesn’t prevent weight loss or dehydration, a direct, liquid feeding
system may be helpful. The most common of these is a PEG
(percutaneous endoscopic gastrostomy) system. We have more
details of this in the MS Society publication Swallowing difficulties.
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Further
information
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MS Society publications
The MS Society has publications on a wide variety of topics,
including information for people just diagnosed, types of MS,
managing relapses, and social care services. For a publications
list and order form visit the website www.mssociety.org.uk
or call 020 8438 0799 (weekdays 9am-4pm).
MS Society website and members’ magazines
Keep up to date with news relating to MS with the MS Society
website www.mssociety.org.uk and UK members’ magazine,
MS Matters. Members in Northern Ireland, Scotland and Wales
also receive national magazines. Details about membership
are on the website and in the Society’s publications list.
MS Helpline
The award-winning MS Helpline offers confidential emotional
support and information to anyone affected by MS, including
family, friends, carers, the newly diagnosed or those who have
lived with the condition for many years. Information about
MS is available in over 150 different languages by speaking
to a Helpline worker via an interpreter. Call freephone
0808 800 8000 (weekdays 9am-9pm, except bank holidays)
or email [email protected]
MS Society National Centre, Information Centre
Based at the MS National Centre in London, the Information
Centre is equipped for visitors to read or locate books and
journals or view videos and DVDs. To request publications,
research articles or other information about MS, visit
www.mssociety.org.uk/library or call 020 8438 0799.
Local information centres
Diet and nutrition © MS Society 12/09
There are MS Society local information and support centres
in many locations around the country. These centres are
staffed by volunteers who can help you with information
about MS and services in your area. Call 020 8438 0799
for the details of your nearest centre.
22
Local branches
The MS Society has a network of over 300 local branches
across the UK. The branches – run by trained volunteers
– provide information about MS and local services, a chance
to meet others affected by MS and take part in a range of
activities. For more information, check the MS Society website
or call 020 8438 0944.
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Further reading
Dietary Supplements and Multiple Sclerosis: A Health
Professional’s Guide, by Allen C Bowling and Thomas M Stewart.
Published by Demos Medical Publishing (2004), ISBN: 1888799900.
Aimed at health professionals, this book summarises the research
behind a range of dietary supplements.
I-Can’t-Chew-Cookbook. Delicious soft-food recipes for
people with chewing, swallowing and dry-mouth disorders,
by J Randy Wilson. Published by Hunter House Publishers (2003),
ISBN: 0897934008. This American book contains recipes for a
wide variety of meals and includes nutritional information for each
one. As this is an American book, the measurements for recipes
may differ from UK scales.
Recipe Collection: Easy-to-Swallow Meals. Produced and
published by the Motor Neurone Disease Association (Revised
1996). Contains a range of meals to suit people with swallowing
difficulties. This book is available free of charge by calling
08457 62 62 62 or writing to: MND Association, PO Box 246,
Northampton NN1 2PR.
Cooking well: Multiple Sclerosis, by Marie-Annick Courtier.
Published by Hatherleigh Press (2009), ISBN: 9781578263011
www.eatwell.gov.uk The Eatwell website, from the Food
Standards Agency, for more information on healthy eating.
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Useful organisations
Disabled Living Foundation (DLF)
Provides information and advice on equipment to enhance
independence.
380-384 Harrow Road, London W9 2HU
Helpline 0845 130 9177 (Monday to Friday, 10am-4pm)
Textphone 020 7432 8009
[email protected]
www.dlf.org.uk
PINNT – Patients on Intravenous and Nasogastric
Nutrition Therapy
A charity providing information and support for anyone using
PEG or other feeding sytems.
PO Box 3126, Christchurch BH23 2XS
www.pinnt.com
Ricability
Researches and publishes consumer reports on products
and services of interest to people with disabilities.
30 Angel Gate, City Road, London EC1V 2PT
Telephone 020 7427 2460 (Monday to Friday, 9am-5pm)
Textphone 020 7427 2469
[email protected]
www.ricability.org.uk
RNIB – Royal National Institute of Blind People
Offers information and support for people with sight problems.
105 Judd Street, London WC1H 9NE
Diet and nutrition © MS Society 12/09
Helpline 0303 123 9999 (Monday to Friday, 8.45am-6pm,
Saturday, 9am-4pm)
[email protected]
www.rnib.org.uk
24
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The Vegan Society
Provides information on healthy eating following a vegan diet.
Donald Watson House
21 Hylton Street, Hockley, Birmingham B18 6HJ
Telephone 0121 523 1730 or 0845 458 8244
[email protected]
www.vegansociety.com
The Vegetarian Society
Provides information on nutrition for vegetarian diets.
Parkdale, Dunham Road, Altrincham WA14 4QG
Telephone 0161 925 2000 (Monday to Friday, 8.30am-5pm)
[email protected]
www.vegsoc.org
References
1 Department of Health
www.dh.gov.uk/en/Publichealth/Healthimprovement/FiveADay/
FiveADaygeneralinformation (Accessed 17.11.09).
2 Food Standards Agency
www.eatwell.gov.uk/healthydiet/
(Accessed 17.11.09).
3 Polman, C.H. et al. (2006) Multiple sclerosis: The guide
to Treatment and Management (6th Ed). New York, Demos
– updated online at www.msif.org
4 Payne, A. (2001) Nutrition and diet in the clinical management
of multiple sclerosis. Journal of Human Nutrition and Dietetics,
14, 349-57.
5 National Institute for Health and Clinical Excellence (2003) NICE
Clinical Guideline 8. Multiple Sclerosis: Management of multiple
sclerosis in primary and secondary care. London, NICE.
6 Jepson, R. et al. (2004) Cranberries for treating urinary
tract infections (Cochrane Review). The Cochrane Library,
Issue 4, Chichester, John Wiley & Sons Ltd.
7 Jepson, R. et al. (2008) Cranberries for preventing urinary tract
infections (Cochrane Review). The Cochrane Library, Issue 1,
Chichester, John Wiley & Sons Ltd.
8 Guay, D. R. (2009) Cranberry and urinary tract infections.
Drugs, 69 (7), 775-807.
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9 Fowler, C J (2009) A UK consensus on the management
of the bladder in multiple sclerosis, Journal of Neurology,
Neurosurgery and Psychiatry, 80, 470-477.
10 Caldis-Coutris, N. et al. (2002) Nutritional management of multiple
sclerosis. Canadian Pharmaceutical Journal/RPC, 135 (5), 31-40.
11 Schwarz, S. and Leweling, H. (2005) Multiple Sclerosis and
nutrition. Multiple Sclerosis, 11, 24-32.
12 National Institute for Health and Clinical Excellence (2001)
A guide for patients and their carers. Working together to prevent
pressure ulcers. London, NICE.
13 Farinotti, M. et al. (2007) Dietary interventions for multiple sclerosis
(Cochrane Review). The Cochrane Library, Issue 1, Chichester,
John Wiley & Sons Ltd.
14 Hawkes, C. H. (2005) Are multiple sclerosis patients risk-takers?
QJM 98(12), 895-911.
15 Gilgun-Sherki, Y. et al. (2004) The role of oxidative stress in
the pathogenesis of multiple sclerosis: the need for effective
antioxidant therapy. Journal of Neurology, 251, 261-8.
16 Bowling, A. and Stewart, T. (2003) Current complementary and
alternative therapies for multiple sclerosis. Current Treatment
Options in Neurology, 5, 55-68.
17 Miller, A. et al. (2005) Vitamin B12, demyelination, remyelination
and repair in multiple sclerosis. Journal of the Neurological
Sciences, 233, 93-7.
18 Ramagopalan, S. et al. (2009) Expression of the Multiple Sclerosis
associated MHC class II allele HLADRB1* 1501 is Regulated by
Vitamin D. PLoS Genetics. Published online: February 6 (DOI:
10.1371/journal.pgen.1000369).
19 Pierrot-Deseilligny C. (2009) Clinical implications of a possible
role of vitamin D in multiple sclerosis. Journal of Neurology.
256 (9):1468-79. Epub 2009.
20 Best Bet Diet Group www.ms-diet.org (Accessed 18.11.2009).
Diet and nutrition © MS Society 12/09
21 Dunne, J. (1997) Carer’s Handbook. London, Dorling Kindersley.
26
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Authors and contributors
Written by James Bailey
With thanks to: Bernice Chiswell, Dr Olga Ciccarelli,
Sharon Grainger, Alison Johnson, Liz Joslin, Dr Anne Payne.
Disclaimer: We have made every effort to ensure that information
in this publication is correct. We do not accept liability for any
errors or omissions, and policy and practice may change. Seek
advice from the sources listed.
Suggestions for improvement in future editions are welcomed.
Please send them to [email protected]
© Multiple Sclerosis Society 2009
Third edition, May 2008
Reviewed and reprinted December 2009
This title will be reviewed within two years of publication.
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MS Society
Multiple sclerosis (MS) is the most common disabling
neurological disorder affecting young adults and we estimate
that around 100,000 people in the UK have MS. MS is the result
of damage to myelin – the protective sheath surrounding nerve
fibres of the central nervous system. This damage interferes
with messages between the brain and other parts of the body.
For some people, MS is characterised by periods of relapse
and remission while, for others, it has a progressive pattern.
For everyone, it makes life unpredictable.
The MS Society is the UK’s largest charity dedicated to
supporting everyone whose life is touched by MS. It provides
respite care, a freephone MS Helpline, grants for home
adaptations and mobility aids, education and training,
specialist MS nurses and a wide range of information.
Local branches cater for people of all ages and interests
and are run by people with direct experience of MS.
The MS Society also funds around 80 vital MS research
projects in the UK.
Membership is open to people with MS, their families,
carers, friends and supporters. You can help the work
of the MS Society by:
•
•
•
becoming a member
making a donation
offering your time as a volunteer
Contact information
MS National Centre
372 Edgware Road
London NW2 6ND
Telephone 020 8438 0700
MS Society Scotland
National Office
Ratho Park
88 Glasgow Road
Ratho Station
Newbridge EH28 8PP
Telephone 0131 335 4050
MS Society Northern Ireland
The Resource Centre
34 Annadale Avenue
Belfast BT7 3JJ
Telephone 028 9080 2802
MS Society Cymru
Temple Court
Cathedral Road
Cardiff CF11 9HA
Telephone 029 2078 6676
National MS Helpline
Freephone 0808 800 8000
(weekdays 9am-9pm)
Website www.mssociety.org.uk
The Multiple Sclerosis Society of
Great Britain and Northern Ireland
is a charity registered in England
and Wales (207495) and Scotland
(SC016433)
ES11/1209