Multiple sclerosis is the leading cause of neurological disability in young adults, affecting over two million people worldwide and nearly one million people in the United States. Multiple sclerosis is three times more common in women than men and is typically diagnosed between the ages of 20 and 50. (1, 2)
The pathogenesis of multiple sclerosis is multifactorial, including genetic, geographical, and environmental factors. Functional medicine plays an integral role in the early diagnosis of multiple sclerosis, identifying key factors contributing to the disease so that neurodegeneration and disease progression can be prevented.
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What is Multiple Sclerosis?
Multiple sclerosis (MS) is a chronic autoimmune disease that damages the central nervous system's brain and spinal cord. Immune-mediated attacks by the body's immune system against myelin, the fatty sheath surrounding nerve fibers, and mitochondrial dysfunction cause neuronal degeneration and an impaired ability to send nerve impulses to and from the brain and spinal cord. (2, 3)
MS affects every person differently. Dependent upon the course of the disease, the International Advisory Committee on Clinical Trials of MS in 1996 defined four types of MS, outlined below.
Clinically Isolated Syndrome (CIS)
CIS is the first episode of neurological symptoms, lasting at least 24 hours, caused by inflammation and demyelination within the central nervous system (CNS). People with CIS are at higher risk of a second neurological episode and a diagnosis of MS. (4, 6)
Relapsing-Remitting Multiple Sclerosis (RRMS)
70-80% of MS patients are diagnosed with RRMS. RRMS is characterized by clearly defined attacks of new or increasing neurological symptoms (relapses) followed by partial or complete recovery (remission). (4, 5)
Primary Progressive Multiple Sclerosis (PPMS)
Up to 20% of people with MS are diagnosed with PPMS. With PPMS, neurologic function worsens as soon as symptoms appear, without symptom relapses. (4, 5)
Secondary Progressive Multiple Sclerosis (SPMS)
Some patients with RRMS will eventually progress to SPMS, in which neurologic function gradually deteriorates, and disability accumulates over time. (4, 5)
What Causes Multiple Sclerosis?
MS is characterized by an accumulation of macrophages and lymphocytes in the CNS. Although the precise cause of MS is unknown, it is speculated that multiple factors are involved in the disease's development and progression. (2, 9)
Genetics
Evidence strongly indicates genetic influence over the development of MS. Females, Caucasians, and people of northern European descent have an increased risk for MS. The observed increased occurrence of MS within families also supports genetic influence over the etiology of the disease. (2)
Genetic variations in hundreds of genes have been implicated in MS risk. Changes in the HLA-DRB1 gene, located on chromosome 6p21, is the most strongly linked genetic factor to MS. (8)
Environmental Factors
One of the more distinguishing characteristics of MS is the notable geographic distribution of the disease. Areas located farther from the equator, such as the northern United States, Canada, Great Britain, and New Zealand, have the highest prevalence of MS. Growing evidence supports vitamin D deficiency as a significant risk factor for the development of MS. Lack of sun exposure, the natural source of vitamin D, helps to explain this geographic distribution. (9)
Studies have also shown that smoking increases the risk of developing MS and is associated with increased disease severity and rapid disease progression. (9)
Theories regarding allergic aspects of MS are evolving. Immune-mediated hypersensitivity responses to a particular allergen characterize allergic reactions. Repeat exposure to allergens can wreak havoc on the immune system, causing immune dysregulation, loss of self-tolerance, and autoimmune destruction. Food allergens, pollens, and molds have been associated with MS disease severity. (10, 11)
Exposure to heavy metals and chemical solvents can contribute to autoimmunity, inflammation, and nerve damage. Accumulation of mercury, lead, and manganese can directly damage neurological tissues but can also stimulate inflammatory autoimmune processes. (9, 12)
Infection
A growing body of research indicates past infection with Epstein-Barr virus (EBV), the virus responsible for causing mononucleosis, and herpes virus-6 (HHV-6) contribute to MS disease risk. Latent viruses may play a role in activating the immune system, triggering MS symptoms and disease activity. (9)
Dysbiosis
Disturbance in the composition of the gut microbiome, called dysbiosis, can negatively influence immune function, intestinal permeability, and systemic inflammation. Increased intestinal permeability, or leaky gut, allows food proteins and pathogens to travel into the bloodstream that otherwise would not be permitted. In circulation, immune cells recognize these foreigners and produce antibodies against them as part of a normal immune response. However, molecular mimicry can occur, in which these antibodies mistakenly target self-tissues that appear similar to the original foreign antigen, triggering autoimmunity and myelin destruction. (12, 13)
Symptoms of Multiple Sclerosis
Clinical symptoms typically develop in young adults between the ages of 20 and 40. Symptoms will vary depending on the disease course and the location of neurological lesions. For most patients with RRMS, relapses develop over days to weeks, followed by periods of remission lasting months to years. (5, 7)
Common symptoms associated with MS include (7):
- Vision impairment: partial or complete vision loss (often with eye pain during movement), double vision, blurred vision
- One-sided numbness, tingling, and weakness
- Lack of coordination, unsteady gait, and difficulty walking
- Bladder and bowel incontinence
- Sexual dysfunction
- Vertigo
- Fatigue
- Cognitive dysfunction
- Mood disturbance
- Problems with speaking and swallowing
Functional Medicine Labs That Can Help Individualize Treatment for Patient With Multiple Sclerosis
Functional medicine labs help practitioners identify the root causes of inflammation, autoimmunity, and neural degeneration. Lab results aid in the personalization of treatment options and the monitoring of health outcomes for patients. Below are some of the most common labs ordered for patients who have multiple sclerosis.
Autoimmune Markers
Advanced autoimmune panels measure autoantibodies to neurological antigens associated with multiple sclerosis. Detection of specific antibodies can pinpoint specific mechanisms behind the disease and open up targeted therapies for early treatment and prevention of disease progression.
Infection
Given the strong correlation of latent EBV with MS, an EBV panel can diagnose acute, chronic, and reactivated phases of viral infection.
Cyrex's Array 12 is an alternative infectious screening panel that measures an individual's immune response to various pathogens that increase susceptibility to autoimmunity.
Gut Analysis
A comprehensive stool analysis assesses the abundance and diversity of beneficial commensal bacteria in the gut microbiome, screens for opportunistic and pathogenic infections, and measures other gut-specific biomarkers of digestive function. This test can establish dysbiotic and other dysfunctional gastrointestinal patterns contributing to inflammation, leaky gut, and autoimmunity.
A leaky gut often perpetuates a leaky brain. Increased blood-brain barrier (BBB) permeability leaves the brain vulnerable to toxic substances, contributing to neurodegenerative disorders like MS. Cyrex panels Array 2 and Array 20 complement each other, measuring antibodies indicative of intestinal permeability and a breached BBB, respectively.
Food sensitivities are a common cause and effect of intestinal permeability, perpetuate the inflammatory cycle, and can contribute to autoimmunity through molecular mimicry. Blood tests screening for food sensitivities can guide recommendations specific to therapeutic elimination diets treating autoimmune conditions, inflammation, and leaky gut.
Environmental Exposures
Environmental toxin tests screen for exposure to and quantify the body's toxic burden of heavy metals and chemicals.
Environmental and food allergies can be diagnosed by detecting IgE antibodies to specific allergen proteins.
Micronutrient Test
A micronutrient test can detect functional and overt nutritional deficiencies associated with MS and neurodegeneration so that dietary and supplemental therapies can be targeted to the patient's nutritional needs.
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Evidence-Based Nutrition for Multiple Sclerosis
From a functional medicine approach, dietary therapy and other lifestyle interventions are paramount in decreasing disease activity. Dietary impacts on MS include maintaining a healthy body weight, improving quality of life, risk reduction of other chronic health diseases, supporting a healthy gut microbiome, and influence over dietary metabolites that directly impact the immune system and brain.
Swank Diet
Beginning in 1949, Dr. Roy Swank started treating patients with MS with a low-fat diet, later coined the Swank Diet in his book published in 1987. The recommended dietary guidelines are as follows:
- No processed foods containing saturated fat and hydrogenated oils
- Saturated fat is restricted to 15 grams daily
- 20-50 grams of unsaturated fat daily
- Fruits and vegetables can be consumed without restrictions
- Red meat and pork are eliminated from the diet for one year. After the first year, 3 ounces of red meat are allowed once weekly.
- Skinless white-meat poultry and white fish are allowed; dark-meat poultry should be avoided, and fatty fish should be limited to 50 grams/1.75 ounces daily.
- Dairy products must contain 1% or less butterfat
- Egg whites can be eaten, but not yolks
- One teaspoon of cod liver oil and a multivitamin are recommended daily.
- Consumption of whole grains, nuts, and seeds is encouraged.
Dr. Swank followed his patients for 34 years, at which point 144 patients were still available for follow-up. Of the 70 patients who continued to follow saturated fat intake guidelines, the mortality rate was calculated at 31%, and the average degree of neurodegeneration was minimal. In contrast, the mortality rate was calculated at 80% and severe disability was observed in patients who had increased saturated fat intake to more than 20 grams daily. (14)
Wahls Protocol
The Wahls Protocol is a modified Paleolithic (Paleo) diet developed in 2008 by Dr. Terry Wahls to improve mitochondrial function and promote myelin production. The WAVES trial demonstrated clinically significant improvements in fatigue and overall quality of life in patients following the Walhs Protocol for 12-24 weeks. (12, 15)
The Wahls Protocol is customizable per patient needs and preferences, designed as a three-tiered system of various levels, increasing in complexity as you advance through the stages. The most basic level, the Wahls Diet, involves three primary elements (15):
- Nine cups of fruits and vegetables daily, broken down into three cups of leafy greens, three cups of deeply colored fruits and vegetables, and three cups of sulfur-rich vegetables
- Gluten- and dairy-free
- Organic, grass-fed, and wild-caught protein
Supplements and Herbs for Multiple Sclerosis
Adding dietary supplements to an MS treatment protocol can be added adjunctively to an integrative MS treatment protocol. Supplements help correct nutrient deficiencies, reduce inflammation, increase autoimmunity tolerance, and improve quality of life and life expectancy in MS patients. (16)
Fish Oil for Multiple Sclerosis
Omega-3 fatty acids in fish oil play a role in normal brain function. Deficiency of omega-3 fatty acids may increase an individual's susceptibility to myelin damage and neurodegeneration; in fact, lower levels of DHA and EPA have been measured in patients with MS compared to healthy controls. (16)
A 2021 systematic review concluded that omega-3 and fish oil supplements benefit patients with MS; positive health outcomes associated with supplementation include reduced relapse rate, inflammatory markers, and improved quality of life.
Vitamin D for Multiple Sclerosis
As discussed above, vitamin D deficiency is a major risk factor associated with the development and progression of MS. A large body of evidence exists supporting the protective effect of at least 400 IU daily of supplemental vitamin D on the risk of developing MS. (17, 18)
Alpha-Lipoic Acid (ALA) for Multiple Sclerosis
ALA is an endogenous antioxidant that can regenerate other antioxidants in the body and scavenge reactive oxygen species. Research shows that oral supplementation of ALA in patients with MS results in reduced expression of inflammatory mediators, improved disability scores, and better walking performance.
L-Carnitine & Acetyl-L-Carnitine (ALC) for Multiple Sclerosis
Carnitine facilitates the transportation of fatty acids into the mitochondria for energy production. ALC functions as a neurotransmitter and a precursor to carnitine. Clinical trials demonstrate that supplementation with L-carnitine or ALC improves medication-induced and MS-related fatigue. (16)
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Summary
Conventional therapeutic interventions for multiple sclerosis aim to reduce the frequency of relapses and palliate MS-related symptoms. Many identified modifiable risk factors contribute to the development of MS. Functional medicine doctors are skilled and trained in using specialty labs to identify autoimmune triggers so that an integrative, personalized approach to medicine can be implemented to prevent the onset and slow the progression of this potentially disabling neurological disease.
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