A symposium focused on lifestyle factors and unconventional medicine as part of the clinical care provided to patients with multiple sclerosis (MS) took place today at the 2016 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC). The symposium, “Expanding the MS Toolkit: Integrating Lifestyle Factors and Unconventional Medicine into MS Clinical Care,” was chaired by Dr. Allen C. Bowling, an internationally recognized neurologist and MS expert.
Bowling delivered the first presentation of the symposium, “Marijuana Update, Diets and Dietary Supplements, Alcohol Use,” where he emphasized that lifestyle and unconventional medicine are “under-recognized and underutilized tools” in MS.
“The lifestyle disease epidemic causes a much greater public health threat than any other disease known to man,” Bowling said, referring to lifestyle diseases such as diabetes mellitus, obesity, high blood pressure, heart disease, and cancer. On the other hand, autoimmune diseases like MS, rheumatoid arthritis, psoriasis, inflammatory bowel disease (IBD), and type 1 diabetes are considered atypical lifestyle diseases, and he believes that lifestyle and MS are linked, either directly or indirectly.
According to Bowling, lifestyle medicine refers to “daily habits and practices [such as diet] that are incorporated into conventional medical care to prevent or treat disease,” whereas unconventional medicine refers to “therapies that are generally not taught at medical schools or provided in hospitals.” Complementary and alternative medicines (CAM) are also popular — in fact, about 50 to 70 percent of the MS patients use CAM.
He believes that integrative medicine is the best option, where there is “integration of lifestyle, unconventional and conventional medicine, but also emphasizes health and wellness of the whole person, [and is] supportive of the clinician-patient relationship.”
Bowling said the integrative model in MS can be defined in seven important steps concerning:
- Disease-modifying medications
- Diet, dietary supplements, and weight management
- Physical activity
- Personal and social well-being
- Tobacco and alcohol use
- Prevention/management of other medical conditions
- Symptom management
He said that MS can be a lifestyle motivator due to the suffering associated with the condition.
Concerning diet, he referred to salt as “one of single greatest dietary harms to health,” noting that the average American consumes about 4,000 mg a day, when the recommended dose is 1,500 to 2,300 mg a day. Obesity is also a concern, and an increased MS risk has been associated with childhood/adolescent obesity.
“Eat food, not too much, mostly plants,” he advised.
Marijuana was also discussed. According to Bowling, “marijuana improves pain, spasticity, sleep. Side effects are well-documented, well-tolerated,” but he added that the “problem is the formulations,” in which medical marijuana standardization, preparation, and purity is a concern.
Regarding alcohol, Bowling said there is “no definitive effect on MS risk, health-related quality of life, [or] disability,” and that some studies have shown that “moderation [is] better than abstention.” He advises, however, that alcohol can have an effect on MS patients in terms of depression, anxiety, and suicidal thoughts, and that its side effects may cause “decreased alertness/cognition, increased reaction times, uncoordination, gait difficulties, fatigue.”
The second presentation, “Tobacco Smoking and MS – Clinically Important but Under-Addressed?” by Dr. Cris Constantinescu, professor at the Division of Clinical Neurology, University of Nottingham, Queen’s Medical Centre in England, focused on the role of tobacco in MS.
“There is ample and epidemiological evidence that tobacco smoking is a significant trigger in MS development,” he said, showing data from a study reporting that MS is more severe in smokers, and that smokers have higher levels of physical and psychological disability.
He highlighted that “smoking is associated with higher risk of MS development,” that it “influences progression of disability,” “is associated with higher risk of premature death,” and that “smoking results in a significant reduction in patients’ life expectancy.”
Constantinescu’s future plans are to further investigate aspects of smoking, perform a qualitative assessment of smoking cessation programs, conduct clinical trials on smoking cessation, and to establish active and effective intervention strategies.
After a short break, Dr. Ellen Mowry, an associate professor of neurology and epidemiology at Johns Hopkins University in Baltimore, presented her work in a talk titled “Vitamin D – Research Update and Implications for Clinical Practice.”
She said there is a link between vitamin D levels and MS prevalence. In fact “the further away from the equator, the higher the [MS] prevalence,” she noted. According to her, individuals with high vitamin D levels have a 50 to 60 percent reduced risk of developing MS.
“Can vitamin D supplements prevent MS? Many questions are still unanswered,” Mowry said. “How much vitamin D? When in lifespan? How long to continue? Unmeasured confounders still possible: infections? ultraviolet light?”
“Is it vitamin D or ultraviolet light that prevents MS? If it is the latter, then vitamin D supplementation will not make sense to use in patients,” she said.
Mowry emphasized that “vitamin D status may matter in utero,” as “moms with higher vitamin D levels had kids with lower probabilities of developing MS.”
Interestingly, in the context of an established disease, MS patients with high levels of vitamin D have been found to have a lower risk of subsequent relapse, suggesting that vitamin D plays a beneficial role in MS pathogenesis. Mowry noted that in MS patients, high vitamin D levels were associated with a “27 percent reduced rate of new lesions,” and “a reduction in IL17 producing T-cells,” which are associated with a pro-inflammatory response.
Mowry and her team are currently involved in the Vitamin D to Ameliorate Multiple Sclerosis (VIDAMS) study, a multicenter trial in the U.S. investigating whether vitamin D supplements might reduce the frequency of MS relapses.
“In the meantime, should patients be supplemented with vitamin D? D2 or D3?” she asked, adding that “several studies have suggested vitamin D3 may be more potent than vitamin D2.”
Mowry concluded her presentation by stating that “vitamin D levels are inversely associated with MS risk and inflammatory activity,” and possibly also with “brain atrophy in early established MS.” She emphasized, however, that the “safety and efficacy of vitamin D supplements for MS, or for its prevention, [is] still not known.”
Dr. Lloyd Kasper, professor of medicine and microbiology/immunology at the Geisel School of Medicine at Dartmouth, was the final speaker of the symposium, and he presented a talk titled “You Are What You Eat – The Role of the Gut Microbiome in CNS Disease.”
He began by explaining that “we start with a mostly sterile gut,” with infants and babies having a low gut microbial diversity. “Between 1 and 3 years of age, our gut microbial communities become progressively more diverse, [and] continue to develop as we eat more solid foods and explore the world around us.”
“By adulthood the gut microbiome is a highly complex ecosystem containing bacteria, virus, and fungi that are symbiotic with the host,” Kasper continued, then “as we age there is progressive loss of the stability that we had as younger adults.”
He said diet has a strong impact on the composition of the gut microbiota. This can lead to changes in intestinal permeability — what is called a “leaky gut,” and also changes in the immune system, promoting, for instance, pro-inflammatory responses. A correct balance in the gut microbiota is necessary for a healthy state.
Kasper showed that germ-free mice (with no or reduced gut microbiota) had a reduced disease severity of experimental autoimmune encephalomyelitis (EAE), a condition in mice mimicking human MS. These animals also had reduced levels of IL-17 and gamma interferon, which are associated with a pro-inflammatory state. Oral treatment with antibiotics can protect mice against EAE.
“The gut microbiome is the common denominator between all the environmental risks factors to develop MS,” Kaspar concluded.
Taken together, the data presented at the symposium suggests that proper lifestyle changes and specific care can have a positive impact on MS.