This transcript has been edited for readability.
Anne Cross, MD: Hi there. I’m Dr Anne Cross and welcome to Medscape’s InDiscussion collection on a number of sclerosis (MS). Weight-reduction plan and life-style components look like concerned in danger of creating MS, and research point out that danger of MS is elevated by genetic susceptibility and by environmental components, of which weight-reduction plan and life-style could play massive roles. Notably, MS is extra frequent in first-world nations, the place the standard weight-reduction plan is excessive in saturated fat and sugars, and in energy in comparison with the weight-reduction plan of individuals in “third-world” nations, the place MS is much less widespread. Many individuals with MS are very excited about dietary and life-style modifications that may enhance their signs or prognosis. A survey a couple of years in the past discovered that 91% of respondents have been excited about diets that may assist handle their MS. I would wish to introduce Dr Ilana Katz Sand, who’s an affiliate professor of neurology on the Icahn College of Medication at Mount Sinai Hospital in Manhattan. As well as, she is affiliate director of the Corinne Goldsmith Dickinson Heart for MS and co-director of the C. Olsten Affected person Wellness Program at Mount Sinai Hospital. One in every of Dr Katz Sand’s predominant analysis pursuits is the function of particular diets and dietary parts in relationship to MS outcomes, and that is going to be the subject of most of our dialogue right this moment. However first, Dr Katz Sand, please inform us a bit about your self. Why did you select medication and the sphere of neurology to check and what led you to MS as a selected subject of neurology?
Ilana Katz Sand, MD: Thanks a lot for having me. It is thrilling to be right here right this moment. By way of my background and the way I acquired right here, fascinated about profession choices manner again when, I wished to do one thing that I felt was necessary and the place I used to be motivated to come back to work day by day and be capable of make a distinction. My father occurs to be a neurologist, and so I had the great alternative to hang around with him after I was a child, earlier than there have been all the foundations and laws we’ve got now. I used to only go together with him into the hospital on weekends to see sufferers. I beloved that intersection between science and having the chance to make a distinction in folks’s lives. That was how I acquired into medication. After all, I had that background in neurology, and so I used to be at all times excited about it from hanging out with my dad. However I believe extra broadly, the mind controls the whole lot, proper? I discovered neurology fascinating for that cause. I used to be a type of individuals who went via medical college and beloved nearly each specialty that I rotated via and thought every time, Oh, this possibly that is it … I really like this! I had a extremely laborious time deciding, however on the finish of the day, I simply stored coming again to neurology. I believe it is such an enchanting subject. After which as I went via my residency, once more, I assumed all of the subspecialties have been attention-grabbing, and I believe I in all probability would have been blissful doing any one in all them. However I simply was drawn to MS as a result of plenty of the sufferers are girls and I seemed round me and noticed you, Dr Cross, because the exception … most people I used to be after I was coaching have been males. I assumed, I relate properly to this affected person inhabitants, and I believe I may be helpful right here when it comes to shared experiences. And I beloved the concept of attending to have long-term relationships with folks. And in order that was one thing I used to be actually excited about. After which I actually beloved how the sphere was altering a lot. It was necessary to me to have the ability to really feel like I used to be capable of do one thing for folks. It was a beautiful time, proper after I was coming into my fellowship in 2011, when the sphere was actually altering lots and we have been making nice progress when it comes to remedies and what we will do for folks. It appeared like an thrilling place to be from a scientific standpoint, but in addition from a analysis standpoint. It was a subject that there is nonetheless a lot extra to do and the place I felt like I may very well be helpful, and I would be capable of contribute going ahead.
Cross: That is nice. I, for one, am very blissful that you just selected neurology and MS, and I am positive your sufferers are blissful too. Dr Katz Sand has lately accomplished and printed a two-center examine of diets in MS; it is an observational examine, and I am questioning when you might inform us a little bit bit about that examine. It had some intriguing outcomes that you just may wish to share with us, and I consider you could have had a second publication on that come out right this moment that you may share with us as properly.
Katz Sand: I will inform you a little bit bit about among the work that we have achieved. After I was a fellow, one of many issues that actually struck me was how little proof we had about weight-reduction plan. I instantly seen, as all of us clinicians do, that that is one thing that so a lot of our sufferers ask about through the scientific visits. However after I requested my mentors about it and seemed within the literature, I discovered that there actually wasn’t lots to information us. On the identical time, I noticed my sufferers who gave the impression to be actually dedicated to good total well being, they usually gave the impression to be doing higher from a incapacity standpoint. I simply thought there should be one thing right here. What I wished to do in the beginning was simply go for it and begin working interventional research. However after all, that was leaping the gun, and other people shortly advised me. I acquired very deserved suggestions saying “You do not have preliminary information for this on efficacy from a feasibility standpoint. If that is even going to work, how are you going to have the ability to run these sorts of scientific trials?” And so I stated, okay, we’ve got to do that in a stepwise trend and determine a extra measured strategy. In order that was how we determined to run our first small pilot examine. In that examine, which we printed in 2019, we randomly assigned 36 girls with MS both to comply with or not comply with a modified Mediterranean dietary intervention. The examine went nice. What we have been there was scientific trial feasibility — we weren’t positive that we would be able to recruit our goal, which was to get 30 sufferers in a single middle in 1 12 months. We have been capable of get to 36 inside 9 months, so we stopped recruiting. We have been actually enthusiastic about that. The opposite issues we have been have been adherence. We have been on the lookout for a goal of about 80% self-reported adherence and we really hit about 94%. Issues went very well from that standpoint. Nearly everybody within the examine accomplished it, aside from one one who form of went lacking and one who sadly moved in the midst of the examine. In any other case, folks have been enthusiastic about it. They have been capable of comply with this system for six months. And so we thought, okay, we will do that. So then we wished to take a look at how can we get some information once more with the objective of finally getting towards massive scientific trials. How can we get information about weight-reduction plan as a illness modifier? We’ve to do observational research. And in order that’s the place the RADIEMS paper is available in. That was the primary piece of labor that we did. The RADIEMS cohort — RADIEMS stands for Reserve In opposition to Incapacity in Early MS — is a extremely great cohort that’s run by my colleague Dr Jim Sumowski, who’s an MS neuropsychologist. We have been so lucky to have him right here at our middle for a variety of years now. It is an NIH-funded cohort. We enrolled 185 folks in 2016 and 2017 into the examine. They have been all inside 5 years of MS prognosis. These are younger folks — common age within the examine at enrollment was 34 years and the typical time for prognosis was about 2 years. The median Expanded Incapacity Standing Scale (EDSS) was zero. It is when folks have been early on so we could not actually have a look at scientific outcomes in that group at baseline. However what we might do was have a look at imaging. And so, what we did was have everybody full a meals frequency questionnaire once they entered the examine at baseline. That was a extremely in depth dietary stock from which we will calculate the place folks fall out on totally different patterns. And so we utilized a rating, which known as a MIND rating; MIND is Mediterranean DASH Intervention for Neurodegenerative Delay. The concept was for it to be a Mediterranean sample, however with particular callouts for gadgets that they suppose are of explicit significance for individuals who have neurodegenerative illnesses primarily based on preclinical literature … so purely observational information and their MRIs. And what I believe is probably the most attention-grabbing discovering from that paper was that we discovered a hyperlink between the MIND rating and thalamic quantity. After all, we do not count on to see widespread atrophy and total decreased volumes. That is one thing that comes later when you concentrate on people who find themselves of their thirties who haven’t got MS, proper? It’s totally totally different. That is one thing that we predict is a pathologic discovering. And so, the truth that we have been capable of see that affiliation in folks so early within the illness was attention-grabbing to us. Attending to the paper that we’re actually enthusiastic about printed right this moment in MSJ (A number of Sclerosis Journal) that is now on-line, there we wished to look clinically at outcomes, which we could not do in RADIEMS. What we did was have a look at our complete annual evaluation cohort. We’re very lucky right here, as a result of starting in late 2018, we began a program via our neuropsychology clinic, which Dr Sumowski directs, and we now run this complete annual evaluation. We’ve the sufferers fill out a bunch of various patient-reported outcomes … questionnaires. They fill out a dietary screener, which is the MEDAS, the Mediterranean Weight-reduction plan Adherence Screener; it is 14 questions and other people get assigned a rating, they usually additionally fill out questionnaires about fatigue and temper, every kind of issues. After which they arrive in individual and do an evaluation the place we do a nine-hole peg take a look at, an SDMT [Symbol Digit Modalities Test], and a timed 25-foot stroll take a look at, and a bunch of different assessments that we do via that clinic. It is a fantastic useful resource for sufferers and we will probably be utilizing this cohort longitudinally for analysis, too. However right here, we simply seemed on the baseline information, and the first end result was to see whether or not there was a hyperlink between their MEDAS rating, the Mediterranean scale, and the A number of Sclerosis Purposeful Composite (MSFC) rating. And the beauty of this cohort is that they’re our sufferers and we requested them plenty of questions. And so, in contrast to in plenty of different dietary research, we have been capable of management properly for lots of confounders. That is a giant downside with observational research of weight-reduction plan — these behaviors are all linked. And so right here we have been really capable of rigorously management for demographic components. We put collectively a really good socioeconomic standing index that seemed not solely at IQ (basically, literacy) but in addition at parental training ranges. That is folded in there. After which we checked out a broad vary of health-related components, too. We checked out diabetes, hypertension, excessive ldl cholesterol, BMI; we even checked out sleep. After actually rigorously controlling for the entire train, all of these components, we have been nonetheless capable of see a reasonably sturdy affiliation between how folks rating on that dietary scale and their MSFC. So, we have been enthusiastic about that, and we additionally discovered associations with an entire bunch of patient-reported outcomes that we reported within the paper. That brings us updated to now.
Cross: I’ll simply reiterate that this paper got here out on October 13, 2022, in A number of Sclerosis Journal if our listeners wish to look it up. Was there any particular element of the MS useful composite, the MSFC, that was related to greater MEDAS scores or…?
Katz Sand: Sure, all three parts. Extra so with the nine-hole peg take a look at and the SDMT, but in addition the timed 25-foot stroll take a look at. The affiliation there was smaller, however sure, the person parts all had these associations.
Cross: And would you thoughts elaborating a little bit bit on the modified Mediterranean weight-reduction plan that you just talked about versus the MIND weight-reduction plan? Are there variations between these two?
Katz Sand: Yeah, it is a good query. Probably not … we known as it a modified Mediterranean weight-reduction plan as a result of when folks hear “Mediterranean weight-reduction plan,” Mediterranean can imply so many issues to totally different folks. We name it modified in that we made our personal changes and guidelines for it. What we did there was emphasize the parts that you just get factors for once you do a MIND rating. As a result of we have been working a pilot examine, we determined to make it a little bit cleaner. We determined that somewhat than de-emphasizing sure parts, we have been going to remove them as a result of it was a pilot examine and it is simpler to do issues that manner, after which contemplate including items again later. We eradicated meat in that examine, and we additionally eradicated dairy from that examine. Once we ran the pilot, these two issues have been out, and that helped us actually emphasize issues which might be emphasised within the MIND rating. Issues like contemporary fruit and veggies. We advised folks, if you are going to eat grains, they should be complete grains. We emphasised fish, nuts …, actually, many of the issues that you just get excessive scores for in MIND. You lose factors in MIND for issues like baked items and butter, that are out once you remove dairy.
Cross: And once you say you eradicated meat, do you imply all meat, like rooster and turkey additionally, or simply crimson meat?
Katz Sand: We did for that examine as a result of we thought it was going to be too troublesome. There have been nonetheless questions that got here up, akin to: “Properly, is meat okay if it is grass fed or is it okay if it is rooster and it is with out antibiotics?” And we stated, you recognize what, that is too nuanced. For the pilot, we’re simply going to make it as clear and as simple as attainable. We’re taking all of it out. And we actually wish to get folks to up their consumption of those different meals, and that may assist us accomplish that. We took it out solely. I believe for future trials, we will focus extra on the general rating and fewer on these particular person parts. I believe it will be much less about eliminating one factor or one other solely and extra in regards to the total sample, which is what we inspired within the pilot, too.
Cross: And so a giant query … you could not know the reply to this, however I believe you might be engaged on it. What’s the mechanism of motion that is perhaps happening right here?
Katz Sand: Undoubtedly engaged on it. So, for the RADIEMS examine, for instance, we collected samples from everybody at 12 months 3 and we’re processing these now. We really acquired information again lately on metabolomics, which our collaborator, Dr Kate Fitzgerald at Hopkins, is engaged on as we communicate. We collected stool samples from folks. We’ve a collaborator right here at Sinai, Dr Jose Clemente, who’s serving to us do these analyses. We’re all of this. We’ve a brand new undertaking that Dr Sumowski and I simply put in with Dr Jen Graves at UCSD, the place we’re actually excited about fascinated about organic growing old as a possible mediator of a few of these results that we’re seeing. However I’d say total, broadly talking, you’ll be able to take into consideration direct results of dietary metabolites after which you’ll be able to take into consideration oblique results which might be mediated via intestine microbiota, for instance. By way of direct results, the whole lot we eat has a chemical construction, similar to our prescription drugs. And these totally different dietary metabolites can have direct results on cells within the intestine. Additionally they diffuse extensively via the peripheral circulation. They bind to receptors on metabolic organs and immune cells and meals that offer you factors on a MIND rating. They are going to be excessive in fiber. They are going to be excessive in antioxidants. We already know that Mediterranean patterns have been proven to have useful results, not particularly in MS populations, however within the basic inhabitants. This has been studied when it comes to the intestine microbiota, and the composition and performance of the microbiota are closely influenced by weight-reduction plan. So which micro organism are current and which metabolites they produce — which in flip goes to have an affect on the native immune system within the intestine after which in plenty of distant results — are actually decided largely by the weight-reduction plan. We predict there are in all probability a number of contributory mechanisms, and we will examine all of them.
Cross: Thanks. One other subject I hoped we might contact upon is life-style and life-style components. Have you ever studied this?
Katz Sand: Sure. Particularly from a scientific standpoint, we’re actually excited about complete care in MS. And we predict that it ought to embody not solely the entire work that all of us do speaking to folks about their disease-modifying therapies [DMT] and watching their MRIs and watching their labs, however really our sufferers as complete folks and being considerate about life-style. I believe there are plenty of components that may make a giant distinction for folks. We all know that if we’ve got two totally different sufferers who begin in the identical place and we put them on the identical DMT, one in all them could do nice and the opposite may not. And so, we actually should be fascinated about what the modifiable components are and the place we will intervene and have an necessary affect on prognosis in our sufferers. Right here at our middle, we have been lucky to have the ability to begin a affected person wellness program, which we launched about 2 years in the past, proper in the beginning of the pandemic. We have been working laborious on this program during the last 2 years and can proceed to take action. When folks come into our wellness program, they meet with our nurse practitioner, with the dietitian, with the bodily therapist, and with the social employee to essentially attempt to get a holistic view and proposals coming at issues from a number of spheres. You understand, we simply have a lot work to do on this space. However after all, I believe the one manner ahead with all of this stuff is to essentially rigorously display that via correct scientific trials, as a result of that is the best way issues really transfer, proper? That is the best way we get clinicians to vary the best way they apply. It is the best way we will encourage our sufferers to do the issues that we predict are good for them, after we can show it. And it is the best way that we get insurance coverage reimbursement for these sorts of companies, which proper now are poorly reimbursed, if in any respect. I believe that is what we have to do.
Cross: Thanks. That is incredible work. It is crucial work and it definitely will influence how practitioners and sufferers perform sooner or later. I wish to thank Dr Ilana Katz Sand for becoming a member of us right this moment and enlightening us on her research on weight-reduction plan and her future plans and research on life-style and want her the very best of luck sooner or later. And congratulations in your model new paper in A number of Sclerosis Journal. That is Dr Anne Cross for InDiscussion.
Katz Sand: Thanks.
A number of Sclerosis
Randomized-Managed Trial of a Modified Mediterranean Dietary Program for A number of Sclerosis: A Pilot Examine
Mediterranean Weight-reduction plan Is Linked to Much less Goal Incapacity in A number of Sclerosis
Dietary Components and MRI Metrics in Early A number of Sclerosis
A number of Sclerosis Purposeful Composite (MSFC)
Kurtzke Expanded Incapacity Standing Scale
The right way to Incorporate Weight-reduction plan Into A number of Sclerosis Care
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