Doctor J. Nicholas Brenton, MD, Neurologist, University of Virginia Health System, talks about a new study that suggests how Keto can make a difference for some people living with MS.
Interview conducted by Ivanhoe Broadcast News in May 2022.
YOU AND YOUR COLLEAGUES HAVE DONE SOME WORK ON NUTRITION AND SPECIFIC DIETS FOR MS. CAN YOU TALK TO ME ABOUT THAT?
DR BRENTON: We looked at a specific diet called the ketogenic diet – a high fat, low carbohydrate diet – and how that diet may impact signs or symptoms of relapsing-remitting multiple sclerosis. There’s been lots of work looking at different types of dietary interventions for MS. At the time we started our study, ketogenic diet had not been looked at. There were lots of promising features about the diet that we thought would promote benefits for an MS patient.
WHAT IS IT ABOUT THE KETO DIET? COULD YOU EXPLAIN TO OUR VIEWERS, THIS IS THE KETO DIET THAT PEOPLE HAVE HEARD ABOUT AND POSSIBLY TRIED TO LOSE WEIGHT AND LOSE WEIGHT FAIRLY SIGNIFICANTLY IN THE BEGINNING.
DR BRENTON: The ketogenic diet essentially mimics a fasting state. In true fasting, you would forgo eating for a period of time and by doing so, your body goes into starvation mode. The ketogenic diet, like fasting, relies primarily on fat as its primary energy source. As a result of fatty acid breakdown, the body makes metabolites known as ketone bodies, which is where the name ketogenic diet originates. For our study, we strictly defined what a “ketogenic diet” was – as in popular culture, the meaning of “keto” has a lot of variation. The diet that we specifically studied was something called the modified Atkins diet, which is a form of ketogenic diet where net carbohydrate is limited to less than 20 grams a day. To give you some insight as to what 20 grams is – a single slice of wheat bread contains (roughly) 20 grams of carbohydrates. In addition to the carbohydrate restriction, we also advised them to increase their healthy fat intake – because remember – in this type of diet, fat is their main energy source. There were no restrictions on protein or fluid intake for these patients.
TALK TO ME A LITTLE BIT ABOUT HEALTHY FATS. WHAT KIND OF FATS WOULD WORK WELL IN THIS KIND OF A DIET?
DR BRENTON: Healthy fats that we promote include rich sources of unsaturated fats – such as avocados, olive oil, nuts/nut butter. We also recommended items that are higher in omega-3 fatty acids – such as chia seeds and flaxseed. Fatty fish – like salmon and tuna – are not only great protein sources but also contain good amounts of healthy omega-3 fatty acids.
IS THAT THE MOST DIFFICULT PART OF THIS FOR PATIENTS?
DR BRENTON: It’s an interesting question. I use 20 grams as a piece of wheat bread, just to give you an example. In general, most of our patients were advised to split up their carbs throughout the day. So, for example, a small number of strawberries at lunch, and then they could maybe have another small amount at dinner or breakfast. Interestingly, we found that carbohydrate restriction was not the trickiest part of the diet – it was the increase in fatty acid intake. It’s contrary to what we’ve all been taught – as we’ve been taught to avoid fats and that fats are bad for us. Thus, carb restriction was easier that increasing fats/health fats for most people.
HOW LONG WERE THEY ON THE DIET? CAN YOU TALK TO ME A LITTLE BIT ABOUT WHAT YOU AND YOUR COLLEAGUES SAW?
DR BRENTON: They were advised that they were going to be on the diet for six months’ duration. The hard part about studying diet in any field, including multiple sclerosis, is it’s very hard to objectively prove that that patient is actually doing what you’re telling them to do. Most studies look at dietary recalls or surveys assessing what they consumed over a certain time period. The beauty of the ketogenic diet (for clinical research) is that you can actually prove that these patients adhered to the diet by measuring breakdown products of ketosis – the ketone bodies. If you’re doing our study diet successfully, then you should be making excessive ketone bodies that can be checked in the blood or urine. For this study, we were having our subjects check ketones in their urine on a daily basis. To do this, our subjects would use a urine dipstick for assessing ketones. The ketone stick was dated in ink so they couldn’t reuse the same ketone stick every day and they had to take a picture of it and email it to our study group every day. If we didn’t get a picture that day or if ketones was negative, that was counted as a non-compliant day. A patient was considered compliant for any day they provided objective evidence of ketosis in the urine via ketone stick detection.
So, after six months on this diet, what did you and your colleagues find?
DR BRENTON: We monitor them for MS progression by doing something called an Expanded Disability Status Scale (or EDSS) exam, which was a detailed neurologic exam, making sure that the symptoms that they were having and the findings that they had on their exam were or were not worsening over time. We also looked at common comorbidities of multiple sclerosis, like depression, fatigue, walking capacity/endurance, and sleep disturbances, and those things were assessed over time. We looked at quality of life, so how the patients felt in terms of physical function, but also in terms of mental function on the diet. We completed these metrics at baseline, and then we repeated them at three and six months on diet. We found that, while on diet, subjects were less depressed, had significantly lower levels of fatigue, and had modestly improved neurologic disability scores. The majority of neurologic improvements included reductions in paresthesias in addition to improvements in bowel and bladder function. Finally, we also saw significant improvements in quality of life, walking speed, fine motor speed, and blood-derived inflammatory markers.
WHAT KIND OF TREATMENTS ARE THERE CURRENTLY FOR MS AND FOR THE RELAPSING REMITTING FORM?
DR BRENTON: Our treatments for relapsing-remitting MS are advancing every day. We have over 20 FDA-approved therapies for adults with relapsing-remitting MS. These medicines are not able to reverse injury or disability that occurred prior to the start of the medicines but are able to reduce the risk of new/future attacks and inflammatory lesions on their brain and spine imaging. We don’t have great treatments for the common comorbidities of multiple sclerosis, as I just mentioned, like fatigue, depression and quality of life.
IT SOUNDS LIKE SUCH A SIMPLE QUESTION, BUT WHY IS IT IMPORTANT TO HAVE A DIETARY SOLUTION FOR PATIENTS WHO ARE STRUGGLING WITH THIS?
DR BRENTON: One of the reasons I became interested in diet and lifestyle habits is because this is a question I get commonly in the clinic from patients and the families: “what should I be eating?” “What should I be doing differently?” “I’m taking this medicine like you’re telling me, but I still have this pain.” “I’m still feeling down.” “I still am tired throughout the whole day.” “I’m doing what you told me to do, but what else can I do as a patient?” Those questions are what led me to research this topic further. To begin, we did a simple survey of patients in our clinic – pediatric and adult MS patients – and asked them if they’d be willing to consider a dietary change and if so, for how long? More than 90% of MS patients were interested in changing their diet if it could possibly help MS. It didn’t matter how old the patient was, the type of MS they had, or how long they had lived with MS – most people were very interested in dietary intervention. What we eat really can help change, forge, and/or reinforce our immune system. There’s a lot of work being done right now in the metabolome (how nutrients are broken down and distributed throughout the blood in our body) and the microbiome (studying the bacteria that reside in our guts). There’s lots of different avenues by which we now believe that diet really can potentially impact multiple sclerosis as a disease and potentially other autoimmune diseases as well.
JUST TO CLARIFY FOR OUR VIEWERS, NOT INSTEAD OF MEDICATION, BUT AS A SUPPLEMENT IN COMPLEMENT WITH MEDICATION TO ATTACK SOME OF THE SYMPTOMS AND SIDE EFFECTS.
DR BRENTON: Correct. Currently, based off the evidence we have right now, diet alone is not sufficient to treat multiple sclerosis, but could be a complementary approach to the treatment of multiple sclerosis.
What do you want to say to patients who see this?
DR BRENTON: I tell patients – as it pertains to the ketogenic diet specifically – that the keto diet is a very restrictive medical diet. Knowing what we currently know, I don’t advocate that all patients go on these diets. I advocate that they join the research to reinforce the safety and the potential efficacy of these diets in the long term. We studied a six-month ketogenic dietary intervention, and nobody has studied this diet long-term (e.g. over years) for MS. While I think mindful and healthy eating is important, there is currently no study that would support a single diet as a treatment approach to multiple sclerosis. I think the most encouraging piece, though, is that there’s a lot of research being done to look at dietary approaches as a complimentary treatment approach for MS.
WHAT’S THE NEXT STEP NOW THAT YOU STUDIED IT FOR SIX MONTHS IN TERMS OF SUCCESS?
DR BRENTON: There is a lot of excitement behind what could be done next. I think there are a couple of approaches. Firstly, we are already looking at how these diets impact both the human metabolome and microbiome. Understanding how the ketogenic diet affects the body’s immune system and the nutrients that contribute to that is really important. Secondly, I do think the next step is going to be an adequately-powered randomized controlled trial where you have a group of patients who are on a sham diet of some sort, whether that be a heart healthy diet or just regular diet that they came in on versus a ketogenic diet. The problem with the randomized controlled studies is that you can’t easily blind somebody to what they eat. In our study, we had no true control group. The control was their baseline diet; however, I do think the next study would be a phase III randomized controlled trial to really look and see what kind of benefits could be garnered from this – hopefully for a period longer than six months.
IS THAT SOMETHING THAT’S IN THE WORKS?
DR BRENTON: That’s something that’s in the planning. Successful research funding for dietary studies has traditionally been difficult – but more foundations and government-funding agencies are recognizing the importance of this research.
FOR OUR VIEWERS WHO HAVE HEARD OF MS BUT MAY NOT HAVE AN UNDERSTANDING OF WHAT’S HAPPENING, CAN YOU EXPLAIN WHAT’S GOING ON IN THE BODY? FOR THE RELAPSING REMITTING COURSE, HOW THAT’S DIFFERENT?
DR BRENTON: We think of multiple sclerosis as an autoimmune inflammatory disorder, essentially where the body’s immune system is not functioning as it should. In MS, the immune system targets the brain and spinal cord and optic nerves. As a result, they get unexpected, periodic flare-ups of troublesome neurologic signs and symptoms – such as numbness, tingling, vision loss, or weakness of the arms/legs. Somebody who has relapsing remitting MS will have periodic flares or “relapses” when there is an active inflammatory attack on the brain or spinal cord, followed by a period of remission, where they typically improve over time.
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:
Joshua Barney
1 (434) 906-8864
Jdb9a@hscmail.mcc.virginia.edu
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