Mount Sinai neurologist, Dr. Ilana Katz Sand, MD talks about a diet that can reduce multiple sclerosis symptoms.
Interview conducted by Ivanhoe Broadcast News in 2022.
For our viewers most people have heard of multiple sclerosis, but they may not have an idea of what’s going on in the system. Could you just describe for our viewers what’s happening in MS?
KATZ SAND: MS is an autoimmune and a neurodegenerative condition. We don’t know exactly what the trigger is. Multiple things, genetics, environment, combining together stimulate the immune system in a way that it becomes overly active in a very specific way such that it attacks the brain, the optic nerves, and the spinal cord. That leads to the experience of neurological symptoms which can really range things like motor problems, which can manifest as difficult in walking or weakness in the hands. Sensory symptoms like numbness, pain, bladder and bowel symptoms. Fatigue is very common, cognition problems, so trouble with thinking and memory, are all common symptoms in MS.
Is there a genetic component?
KATZ SAND: There is definitely a genetic component that we’ve identified. There are certain genes that if people have them, we know that there are higher risk for developing MS, but that’s definitely not the end of the story. It explains overall a relatively small proportion of the overall risk. For example in people who are identical twins, it’s not 100 percent. If one has it that the other is going to have it. Of course they have certain environment, we think there’s a very large environmental component to MS as well.
What is the age range for first offset?
KAZT SAND: Most of our patients are going to be women between the ages of 20 and 40 when they’re diagnosed. There’s a huge range. You can also be 75 at the time of diagnosis and pediatric cases also occur.
Are there some symptoms that are hallmark or telltale signs?
KATZ SAND: Yes. One of the syndromes we see commonly called optic neuritis, which is an inflammation involving the nerve that communicates between the eye and the brain. That manifests as a loss of vision, which is often painful. That’s a very common presenting symptom for MS. Some of the other ones would be some of the ones that I’ve mentioned such as sensory symptoms.
Is there a cure?
KATZ SAND: No. Not yet, it is what we’re working toward, but not at this point.
In terms of treatment, is it treatment of the symptoms, or are there other things that you can do?
KATZ SAND: It’s both. I usually divide treatment into two broad categories. One is what I would refer to as the category of disease-modifying therapies. Those are therapies that we put people on because we think that they actually change the course of someone’s illness and actually have an impact on prognosis versus, as you mentioned, symptom management. That’s the other category, things that we can do to help people optimize their daily function. Once certain symptoms are there, we can’t take them away, but we can make them manageable. There are many things that we can do to help people live full and healthy lives even if they do have some symptoms.
Is that mostly medication or are there other lifestyle factors or other ways to modify the course of the disease?
KATZ SAND: Definitely both. We try for a comprehensive and holistic approach to the MS care. That is a combination of pharmacologic treatments as well as non-pharmacologic treatments. Those include lifestyle approaches such as diet, exercise. We also work with helping people manage their sleep and managing stress in their lives. There’s a lot of different things that we try to work on.
Talk to me a little bit about diet and the Mediterranean diet in particular. Why was that a focused area of research for you?
KATZ SAND: I got interested in diet when I was first training as a fellow neuroimmunology. I found that almost every single patient who came in was asking me, “what can I do?” I searched the literature. I think it’s one of the main reasons why we should be pursuing this topic as a research topic is because it’s something that people who live with MS are interested in. Right away that makes it something that’s important. The other piece to that though, is that from a scientific standpoint, we have had increasing levels of evidence over the past few years showing us that we think diet is important. We know that diet is a major way that humans interact with their environment. You take in this food, which is broken down by the digestive system and by the bacteria that live there that are heavily influenced by what you eat. Then there are all these interactions that happen between the metabolites and the food. We can think about them in the same way that we think about pharmacologics. They’re able to interact with the immune system, they diffuse into the peripheral circulation, the metabolites from food. They can cross the blood-brain barrier and get into the brain and the spinal cord and have local effects there. From a biologic basis, it actually makes a ton of sense.
The Mediterranean diet?
KATZ SAND: We had a few choices. One was to just look out on the Internet and see what are the popular diets that our patients are interested in. The other approach, was considering the best evidence from the basic science literature and looking for what kind of a diet would have some of the components that might be of benefit. That put us toward looking at foods that are going to be high in anti-oxidants. Things like fruits, vegetables, and olive oil. When we thought about that, a Mediterranean type of pattern made sense from a scientific standpoint. We wanted to end up with something that we can educate people about. This is a pattern that we know from general health and wellness studies, is healthy for everyone. It is helpful in maintaining a healthy body weight, in preventing cardiovascular comorbidities like diabetes and high blood pressure. Those things we already know are associated with prognosis and MS. That was a good place to start and it’s something that the whole household can do. We wanted something that’s going to be really a lifestyle change and not the diet. This fit from multiple angles. The basic science research not only in MS, but in other neurodegenerative diseases was very helpful and suggestive to us as well.
How did you study it? How did you really hone down and see whether this would be a benefit?
KATZ SAND: We have done a few studies in the last few years. The first one that we did was actually a small pilot interventional study where we randomly assigned 36 women with MS either to follow or not follow this Mediterranean style diet for six months. It was mostly to see whether we actually could get people to sign up and be excited about it and we were pleased with the way the study went. People volunteered and we did a great job in the study in terms of how well they were able to adhere to the recommendations that we gave to them. The study was mostly about feasibility and yet we were able to actually see some effect on outcomes. People in the group that had the intervention did better and they had less fatigue. We had them fill out a ton of questionnaires. But they had less of an impact of their MS symptoms on daily life. They even had a lower disability score at the end of the study compared to the group that didn’t have the intervention.
What is the disability scores that survey measured?
KATZ SAND: There were a couple of different ones that we use, but this was actually an objectively measured one that is a standardized version of the neurological exam in that particular study. That study told us that we were on the right track. Our ultimate goal was going to be toward what we’re still working toward, which is a large clinical trial and we’re still working toward that. In order to get there, the next piece that we needed was some observational data to show us, if we were on the right track. Do we think that this is actually a disease modifier? Do we think that this is something that is actually linked with the underlying pathology of MS? And do people who have different dietary habits actually have differences in how they do in the long term?
Regarding your most recent work, what have you found?
KATZ SAND: The recent paper that we just published in multiple sclerosis journal builds on what we call our comprehensive annual assessment program. We have a new program here that we’ve been sending our patients into since 2018. In addition to seeing their physician in the office and getting a yearly MRI which is recommended for MS, we now have this program where people get a once a year really comprehensive assessment. It’s done through our neuropsychology clinic. They get a really deep look with some objective measures on how they’re doing. They get a disability assessment where they’re timed putting pegs into a dish. There’s cognitive testing and there’s a bunch of different surveys that people fill out with questions about their mood, their fatigue level, their ability to walk, and how they think their memory is doing. At the same time, we also capture a lot of information about their health behaviors. We capture information about their diet. We use something called the Mediterranean diet adherence screener or the Meatus, which is the scale that we used in this new paper. It’s a scale from zero to 14 and depending on your answers to these different questions, you will end up with a different score. You end up with a score from 0-14 and that allowed us then to see if there is there a link between people’s score on this diet scale that we’re using this Mediterranean screener and their level of MS related disability. We can look both at the objectively measured parts that are done by an assessor who doesn’t know about that person’s diet. It’s a blinded assessment essentially. As well as we can look at the questionnaires that people filled out and see what they say and what their experience is. We also kept her information about physical activity and smoking and all the other things that make diet research hard. It is very hard to isolate the diet from all those other things that hang together. What we were able to do here was because we collected so much information from people, we were really able to look at this very rigorously and look at the diet while controlling for all those other factors.
When you look at the diet and you’ve controlled for everything else, the smoking and the other lifestyle factors, wdid you find?
KATZ SAND: We find that there’s a significant relationship there. The better people scored on that scale, the more their diet looks like a Mediterranean diet, the lower their scores were in terms of MS related disability across the board.
When you have that information, you’re armed with that information, what does that suggest to you?
KATZ SAND: It’s a cross-sectional study, meaning that it was captured at a point in time. It’s a little hard to know. What we really need to do to know this for sure is to conduct big randomized trials. That is where we’re going with it. This to me is a justification for going ahead with that and we’re hoping to be able to secure funding to do that. What this suggests is that people got here somehow. Even though it’s a cross-section, they got here somehow. This suggests to me that diet is important.
What do you say to those patients, across the country who are either newly diagnosed with MS or who have been diagnosed with MS, even though you still need a randomized large trial to have the science, before all of that information comes out, what would you suggest?
KATZ SAND: I do always point that part out when people ask me well should I do this diet or that diet or should I do this Mediterranean diet, the science is not quite there yet to say one diet over another. However, I think there are some things that are very reasonable to recommend now. There are a few things that I think, no matter what diet people are studying or what they think might be helpful, there’s a few things that we can all get behind.
And what are those?
KATZ SAND: These things are when you’re able to prepare meals at home whenever possible. We know that when you prepare meals yourself, you know exactly what goes in it, looking for things like colorful fresh fruits and vegetables as much as possible, and staying away from ultra processed foods as much as possible. We always teach our patients to shop the perimeter of the grocery store where all the fresh stuff is. Frozen vegetables are also wonderful. We are talking about avoiding things that ultra processed up in the middle of the store. The cookies, chips, things that come in a box. The more I think we can look for stuff that’s fresh, the more likely you are to get some of these nutrients that we think are important. Then we encourage people that eat grains to steer toward whole grains rather than highly refined grains that you find in white rice or white bread. Steer towards the stuff that’s darker in color and that’s labeled as multigrain or whole wheat. Those were some recommendations that no matter where people fall out on the spectrum of what diet they think might be best. It’s very reasonable to try to help them move in that direction now.
You had mentioned earlier that this diet in research has shown beneficial for people with Alzheimer’s and just forms of dementia could help with some of the processing there. Is there that link between the Mediterranean diet and portions of the brain?
KATZ SAND: We have done a little bit of research looking at this. There has been good work in Alzheimer’s and aging literature, looking at structural brain MRI to look to see which parts of the brain are different, and which parts are seem to be related to diet scoresWe had another paper in-between these two that did look at structural MRI in a different patient population. We were looking at people with very early MS in that study. it was a little harder to see clinically because fortunately, these people were very early in their diagnosis. Physically, they did not have a lot of MS related disability or really cognitively either. We were able to see in that paper a relationship between people’s Mediterranean diet score and the volume of their thalamus. The thalamus is a deep structure in the brain that has actually been shown to be the first thing that’s affected in MS. We know that people with MS will have decreased volume of certain brain structures and their whole brain volume will be decreased compared to other people their age who don’t have MS. As people live with the disease longer, those issues do tend to get worse. Here we were able to see in a group of people with really early MS that there were differences in that volume of the thalamus, which we know is tied to more widespread differences later. We were able to see this in people who on average won’t live two years from the time of diagnosis.
What was the population in the most recent study?
KATZ SAND: The population in this most recent study was a much wider, more representative cohort. I would say it’s very representative of the general population of people who live with MS and demographically as well. In terms of age and sex, race, ethnicity, a very nice representative sample.
Is there anything I didn’t ask you that you would want to make sure your viewers know?
KATZ SAND: think it’s important for people who have MS to make sure that they’re asking these questions. Sometimes people think that it’s not the doctor’s place to counsel on nutrition, but I really do think that it should be. At minimum, people can always refer to the National MS Society’s guidelines. I think if you’re looking for help and you’re able to work with the dietitian, that’s always wonderful.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Elizabeth Dowling
(347) 541-0212
Elizabeth.dowling@mountsinai.org
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