As a vegan what supplements do I need to take?
I am in the process of researching the dietary landscape for people with MS and will not be ready to make any firm recommendations for some time, but I can make a recommendation of what diets to avoid. The first is a strict vegan diet without supplements.
My index patient was an Asian woman, in her mid-20s, with RRMS who referred for a second opinion about worsening MS symptoms and escalation therapy. She was on glatiramer acetate and was complaining of progressive visual disturbance and painful pins and needles in her hands and feet. When I saw her there was little doubt she had RRMS, but it was clear to me she had superimposed vitamin B12 deficiency as well. She had bilateral visual failure (6/60 vision) with large central blind spots and when I looked into the back of her eyes her optic nerve was very pale indicating she had lost a lot of nerve fibres in the eyes (optic atrophy). The clue to the diagnosis was that she was pale and had a smooth red tongue (atrophic glossitis) and she had lost sensation in her feet and her tendon reflexes were depressed (neuropathy). Other problems included excessive fatigue, shortness of breath with minimal exertion, memory loss, poor concentration and attention, irregular periods and patchy hair loss. When I asked her about her diet she volunteered to be a vegetarian for most of her life and had become a strict vegan in the last 5 years. Apart from the intermittent use of iron supplements for anaemia, she was not taking any supplements. When I checked her blood results she had very low vB12 levels and mild anaemia with a mixed pattern due to a combination of being iron and vB12 deficient. Tragically this patient’s visual function did not recover on vB12 supplements and her peripheral neuropathy became very painful presumably as the nerve fibres started to recover in her feet they started to fire aberrantly causing pain. She is now registered legally blind; a tragedy as her visual loss was preventable.
In addition, to this patient in my 5-years of doing the physician’s clinic at Moorfields eye hospital under Professor W. Ian McDonald’s mentorship, I must have diagnosed subacute combined degeneration of the spinal cord due to dietary vB12 deficiency in at least 5 other patients who were vegans. I have also seen a remarkable case of a lady, who was a vegan, who presented with pins and needles around the mouth and a numb tongue. She was not vB12 deficient as she was taking vB12 supplements, but when I did her peripheral metabolic profile she was profoundly zinc deficient and also had low levels of selenium. Within a week of going onto zinc and selenium supplements, her symptoms resolved.
From an evolutionary medicine, perspective veganism is not natural. We evolved as omnivores, i.e. vegetable and meat eaters; our metabolism tells us this and hence a strict vegan diet is unnatural and unbalanced. If you are vegan you need to make sure you supplement your diet with the following essential nutrients and minerals:
- Vitamin B12
- Iron
- Zinc
- Iodine
- Calcium
- Essential fatty acids, in particular, omega-3 fatty acids
The following may need supplementing:
- Vitamin D (you can get sufficient from sunlight exposure at the correct time of the year). At Barts-MS we recommend that all our patients and first- and second-degree relatives take vD supplements according to the vD Council’s recommendations.
- Selenium (you can get sufficient selenium from some vegan food sources, e.g. brazil nuts, mushrooms, sunflower seeds and beans)
- Protein (adults can get enough protein from a vegan diet, but children and people in a catabolic state, for example with certain diseases, may need additional protein sources)
If you have children on a vegan diet you should be careful about making sure they get enough protein and the above supplements. If not they may become stunted.
The bottom line; strict veganism is not natural in health and/or disease and is deficient in several key nutrients and minerals that need to be supplemented. This is a problem for people who are on the breadline; supplements are relatively expensive and hence vegan diets put poorer people at greater risk of the health consequences of an inadequate diet.
Please note that vB12 is essential for myelin metabolism and is the reason why when you are vB12 deficient you get a mixed demyelinating and axonal nerve loss picture in the optic nerves, spinal cord and peripheral nerves. There is a body of literature showing that pwMS tend to have low vB12 levels and this may be an indication of them needing more vB12 that the average person as it is consumed as part of myelin turnover. I therefore suspect that pwMS are even more senstive to vegan diets than people without MS.
Baroni et al. Vegan Nutrition for Mothers and Children: Practical Tools for Healthcare Providers. Nutrients. 2019 Jan; 11(1): 5.
As the number of subjects choosing vegan diets increases, healthcare providers must be prepared to give the best advice to vegan patients during all stages of life. A completely plant-based diet is suitable during pregnancy, lactation, infancy, and childhood, provided that it is well-planned. Balanced vegan diets meet energy requirements on a wide variety of plant foods and pay attention to some nutrients that may be critical, such as protein, fibre, omega-3 fatty acids, iron, zinc, iodine, calcium, vitamin D, and vitamin B12. This paper contains recommendations made by a panel of experts from the Scientific Society for Vegetarian Nutrition (SSNV) after examining the available literature concerning vegan diets during pregnancy, breastfeeding, infancy, and childhood. All healthcare professionals should follow an approach based on the available evidence in regard to the issue of vegan diets, as failing to do so may compromise the nutritional status of vegan patients in these delicate periods of life.