Did you know two lifestyle options, i.e. exercise and diet, are probably the most effective add-on neuroprotective therapies for treating MS?
Exercise induces long-lasting changes in the brain, which includes upregulation of growth factors and release of endorphins, that are almost certainly neuroprotective. Similarly, diets (caloric restriction, intermittent fasting and low-carbohydrate ketogenic) stimulate metabolic pathways that are both anti-inflammatory and neuroprotective. Why would someone with MS not want to hack their metabolism to derive these benefits?
CoI: none in relation to this post
#T4TD = Thought for the Day
P.S. Please note that if you are overweight you need to lose weight first to exercise properly. Exercise, without a change in your diet, is not an effective weight-loss strategy.
Agree with everything except ketogenic diet. Personal experience (may be correlation not causation but relapsed approx 3 weeks after starting ketogenic diet) plus conflicting info from both Swank and Prof Jelinek who both say low fat diet is best for MS.
Common to calorie restriction and intermittent fasting is ketosis with one of the ketone bodies (hydroxybutyrate) stimulating the hydroxycarboxylic acid receptor 2, which in turn activates the NRF2 pathway (neuroprotection). I am not sure the Swank or Jelinek diets are backed-up by biology. But then diets are personal things and often involve cultural and belief systems. As always it is horses for courses. You may want to read this blog post.
https://multiple-sclerosis-research.org/2020/02/could-diet-be-the-new-add-on-dmt/
Re. ‘ intermittent fasting and low-carbohydrate ketogenic…’ These boost testosterone levels apparently in men.
Which supports the quote ‘Men with MS are more likely to have low testosterone levels than men without MS’ (MS Trust website).
My experience of MS services has been that these factors are simply not emphasised by professionals. In fact in my case (as someone with MS who read the research about this before I was officially diagnosed) actively dismissed as something unlikely to make a significant impact. It’s astounding that practice lags behind evidence so much in this regard, especially in teaching hospitals in London where I am seen. Of course there are a whole host of psychological, social and economic factors which impact on lifestyle interventions but education and emphasis in the system is surely self-management 101?
Nicky most doctors and neurologists don’t get training in lifestyle interventions and our practice is time-poor and hence we don’t have time to go into these issues in great detail during a clinic appointment. Saying this makes me realise this is a poor excuse.
If somebody is lean and is on tecfidera, do you think intermittent fasting or ketogenic diet can still be beneficial?
I have no idea. This is why we need studies. You put forward a hypothesis and then test it. The problem with dietary interventions is that they are very hard to test by doing trials.
Being lean is not guarantee that you are healthy. There is a well describe metabolic syndrome called TOFI (thin on the outside fat on the inside) that is driven by insulin resistance and visceral fat accumulation. So I think dietary interventions apply to everyone regardless of your BMI.
What about fiber? Afaik there is some evidence that dietary fiber helps with the gut microbiome, and it’s the whole reason propionic acid is being looked at. How are you supposed to get enough fiber on keto? It seems like it would be really hard to get from vegetables alone.
You can eat as much fibre as you want on keto. By definition, fibre is not digested by our own metabolism, but passes into the colon for the bacteria to digest.
It seems hard to get decent amounts of fiber on keto. Most vegetables don’t contain that much. Rice, whole grains and potatoes are out.
From personal experience and as a trainer, it is very difficult to exercise effectively in a body that is not fuelled correctly.
Fat burning exercise can be a long slow run or exercise in the morning before breakfast. But I advise everyone to eat after a run – carbs and protein depending on the intensity and duration.
And adding what I call “incidental exercise” helps too. I have kept my training up during lockdown but I have gained weight just because of all of the steps I’m not doing, that I normally wouldn’t think about: the walk to the tube station, walking around a large open plan office, taking the stairs to the third floor. I would rather control this by increasing activity than changing my diet (the tyrrany of the veg box that needs to be used up), but it requires a more conscious effort.
Sarah, you definitely don’t need carbs if you are keto-adapted. What you are advising is dogma and against millions of years of evolutionary biology. There are many examples of perseverance hunting when humans exercise for days without eating. The body is amazingly adaptable, which we seem to ignore.
I always feel better when I run on an empty stomach; blood diverted to the gut for digestion is a handicap. Ask any elite athlete, particularly marathon runners, performing at their limits.
I am a marathon runner, with around 15 marathons and ultras under my belt. We can run for around 90 minutes using stored glycogen, if a runner does not take on fuel in a marathon they will “hit the wall”. Eliud Kipchoge would not have managed to run a marathon in under 2 hours without carefully calculated fuel intake.
Prove it; that is the problem with dogma. There many marathon runners who live and run marathons on ketogenic diets. Maybe someone should test the hypothesis 😉
You may find the following article of interest: https://www.outsideonline.com/2397274/runners-keto-diet#close
I’m aware of that study but would not think the result particularly encouraging if I was thinking of switching to a ketogenic diet.
There is a lot of money in marathons so no doubt a lot of research going on. I am not aware of any elite runners winning marathons on keto diets yet though.
Boa cena
The irony is that if exercise and diet were the only remedy for MS, everyone would be using/doing it and things would be so much better. It’s as if the fundamental requirement (bother) to exercise and diet were the things doctors are created to find a way around. Astonishing that the very design of the human structure is hacked as a business opportunity.
No business here; simple advice. You could argue that DMF and the other fumarates are simply mimicking ketosis. But when the fumarates were discovered nobody knew about their mode of action.
Could it work to take DMF on top of other DMT’s? Could that be a thing?
With intermittent fasting I’d love to learn more about the best diet to eat during the non fast period. Would really appreciate any tips of where best to look/books? No idea where to start.. I find diet stuff online a bit of a minefield..
Do you like to read or watch?
Diet and MS: A Neurologist’s Perspective
Dr. Bhargava
See min 45
A Diet Mimicking Fasting Promotes Regeneration
and Reduces Autoimmunity and Multiple Sclerosis
Symptoms
https://pubmed.ncbi.nlm.nih.gov/27239035/
Fasting Activates Fatty Acid Oxidation to Enhance
Intestinal Stem Cell Function during Homeostasis
and Aging
https://www.google.com/search?q=Fasting+Activates+Fatty+Acid+Oxidation+to+Enhance+Intestinal+Stem+Cell+Function+during+Homeostasis+and+Aging&ie=utf-8&oe=utf-8&client=firefox-b
Intermittent fasting attenuates lipopolysaccharideinduced
neuroinflammation and memory
impairment
https://pubmed.ncbi.nlm.nih.gov/24886300/
Mark mattson
More?
This!!!! Absolutely. There are MS gym or exercise programs for every level of ability. I’ve been working out daily since 2017. I’ve had vast improvements in mobility (unexpected by PT). If I take a break – I start to decline physically within a week.
Along with reducing inflammatory foods and figuring out mineral and vitamin deficiencies (which are often due to genetic SNPs and microbiome), we have tools.
I see so often in groups that people hope a DMT will improve mobility but it’s a three pronged approach that’s necessary.
This!!!! Absolutely. There are MS gym or exercise programs for every level of ability. I’ve been working out daily since 2017. I’ve had vast improvements in mobility (unexpected by PT). If I take a break – I start to decline physically within a week.
Along with reducing inflammatory foods and figuring out mineral and vitamin deficiencies (which are often due to genetic SNPs and microbiome), we have tools.
Speaking to the issue with ketogenic diet for some – having failed a popular paleo diet, I have since found out I have a genetic SNP meaning saturated fat is never good. So many of these diets swear by “good” saturated fats. However I need substantially more protein and good fat than allowed by another popular protocol.
Protocols and blanket recommendations in general don’t meet individual needs. And can be a liability.
I see so often in groups that people hope a DMT will improve mobility but it’s a three pronged approach that’s necessary.
So glad to see the neurological community recognizing this!
Please can anyone recommend any particular free online exercise videos to help more advanced MS patients who need to regularly use a wheelchair? Thank you.
Hi,
You could give ‘MS Gym’ a try.
I belong to the MS Gym. In membership there is an amazing “bed built” program, but many free resources for both chair and those walking.
KC – how do we find out which vitamins and minerals we are deficient in? Where is the best place to start? I’ve been religiously taking vitamins as recommended by George Jenk for the last several years, but I do wonder if they are the right ones or if I’m missing a crucial trick? Many thanks.
I prefer to improve deficiencies (blood work). Any time I’ve strayed from this, it’s gone badly. I have a real distrust of any protocol that says we “should” take anything, because we are all different (gut microbiome, genetics, diet, even regional differences in soil mineral levels etc.)
I also wonder at the propensity in neurological circles to use supplements as pharma (high dose biotin, vitamin D3, etc.) rather than tweaking biochemical pathways. We MAKE the hormone vitamin D – if we are not making it, what is the limiting factor to producing it?
For this reason, when tending to the science/supplement bit, I surprisingly have the most help with a naturopathic doctor who will pull out hormone and other biochemical pathways and help me figure it all out.
I’d be interested to know what’s classed as enough exercise? I walk my dog twice a day, try to keep active in my house and garden and have cut down on carb intake. My BMI is within normal limits, I weigh 9 stone. Fatigue and pain means I struggle to do more than I’m doing now. No way am I going to be able to run marathons!
I’d be interested to know what’s classed as enough exercise. I walk my dog twice a day, try to keep active in house and garden. I take a statin and supplement with vitamin D, magnesium and B vitamins. I’m 62, weigh 9 stone and have reduced my carb intake over the last 2 years. Fatigue and pain means I’ll never be running a marathon. I hope what I’m already doing is enough.
The cns has to be challenged
Fasting is just another way of
Like exercise ,reading, talk to people ,learn a new language ,learn a new instrument .. Etc
See this video of some one that had a stroke, look at the brutal intensity of this exercixes
https://medicalxpress.com/news/2019-08-high-intensity-boosts-survivors-skills.html
High-intensity step training boosts stroke survivors’ walking skills
“Rehabilitation that allows walking practice without challenging the nervous system doesn’t do enough to make a statistical or clinically significant difference in a patient’s recovery after a stroke,” Hornby said
You must feel tired becasuse you workout hard
KC – thank you for reply re deficiencies. Had discussed this a few years ago with gp, who I think was just humouring me.
I was told to not waste my money on magnesium supplements by an ms Neuro. Yet Mg deficit turned out to be the driving force behind my low D levels and some other symptoms. Your neuro is in good company lol.
Yep
Study shows magnesium optimizes vitamin D status
https://medicalxpress.com/news/2018-12-magnesium-optimizes-vitamin-d-status.html
Have to feed the enzymes so they do their thing! I had the same experience with Mavenclad.
I completely agree with this. I was diagnosed with highly active RRMS at 42 years old following 3 relapses within a 6 month period which were sensory issues. I was treated with Lemtrada/Alemtuzumab in 2016&2017 as a first line treatment. I have been relapse free ever since. Perhaps I am one of the lucky ones in that MS hasn’t impacted on my life too much and I was offered Lemtrada/Alemtuzumab as a first line therapy thanks to a very forward thinking Neurologist. My Sister also has MS so my diagnosis journey was extremely quick; I wanted to hit it hard with treatment. I exercise about 4 times per week (HIIT and bootcamp workouts) as well as intermittent fasts 2-3 times per week. Who’s to say whether I would be in this very well state with or without the combination of treatment and exercise but for me I wouldn’t want to risk not exercising. It keeps a positive mindset as much as anything else.
https://osf.io/preprints/nutrixiv/rdjfb/
A plant-based, low-fat diet decreases ad libitum energy intake compared to an animal-based, ketogenic diet: An inpatient randomized controlled trial
Interesting pre-print I’ve just come across
Hi Prof G, I’m a doctor with MS, I had a run in with PML last year (natalizumab/JCV+ve), fortunately for me a very early pre symptomatic radiological diagnosis. I tolerated a pretty intense course of steroid for the IRIS and am now back to full strength and work. Currently on copaxone and MS seems stable. I love exercising and am doing it most days. I’ve been looking at keto for sometime, Terry Wahls modified keto has some appeal with its volume of real foods. I started on a regular keto plan about a month ago and so far so good, no bad breath (not that I’ve been told of anyway..) and exercise going well. I wondered if you had any thoughts on keto in a post PML/IRIS person – good/bad or who knows…? Thanks
Sounds like you have done well. I am not a metabolic expert, but I don’t see any literature that suggests keto-adapted people are immune deficient, etc. I suspect that if you are someone who has metabolic syndrome, prior to biohacking your metabolism by going keto, will improve their metabolic health and hence be more resilient to infections. The latter is the logic about getting obese people to go low-carb as part of the COVID-19 rehabilitation program.
Thanks, no I don’t have metabolic syndrome, these recent posts on keto very timely for me, I appreciate your thoughts – interesting re obesity, low carb and COVID. While I’ve got you…….on a different note, what is your current preferred DMT for post PML for someone normally functioning in the world with low disease burden and few relapses RRMS? Thanks