Contents

02 Is there an MS diet?05 Vitamin D08 Vitamin B1209 Essential fatty acids10 Antioxidants11 Special diets15 Diet and your MS18 Preparing food22 Managing your weight24 Further information25 Further reading26 Useful organisations

Eating is more than just a necessity. It can be a social activity,and it can make you feel good. You can adjust what food you eat to suit your tastes, needs and lifestyle. You can be in controlof what you eat. And changes to your diet might improve yourquality of life and well-being.

There are many claims made about how diet can help youmanage your MS. It can be hard to know what evidence backsup these claims. In many cases there isn’t strong evidence atall. This booklet looks at the evidence that does exist, to helpyou make up your own mind about what you choose to eat. It also looks at the kind of healthy diet most people should be aiming for, and how to get a balance of the different food groups.

You might find that symptoms of MS affect what you can eat or how you prepare meals. This booklet includes tips onpreparing food, covering everything from planning meals toclearing up afterwards, so that you can carry on eating the food that you enjoy.

In this booklet we refer to other organisations that can help with particular issues – just look for the . You’ll find theirdetails in ‘Useful organisations’ at the back of the booklet.

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Diet andnutrition

Fourth edition August 2012

11MS EssentialsFor people living with MS

This publication is available in large print (22 point) and audio CDCall 020 8438 0799 or email infoteam@mssociety.org.uk

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Is there an MS diet?

I think diet is very important for us MSers, but the key is to tailor it to meet your own requirements. We’re all different. – Heather

Living with MS is different for everyone. Some people say that certain foods help them and other people don’t notice any difference. But many people with MS say that when they eat well, they feel better. For most people with MS, the best dietis a healthy, varied one.

Some people with MS say that following a specific diet has made a difference to how they feel, perhaps by reducing the number of relapses they have or by improving their overall quality of life. But other people don’t feel this way, and there is no conclusiveevidence that special diets are effective in managing MS.

We look at some of the more popular diets that are suggested for MS on pages 11 to 14.

Research into diet and MS

There has not been a lot of research into diet and MS, which can be frustrating. One reason is that effective studies into dietcan be difficult to design and control. Diet is part of everyday life,and people eat different types of food. So it’s almost impossible to ensure everyone in a trial eats exactly the same thing, over along period of time. Food studies need to go on for a number ofyears to be useful, which also means that dropout rates tend to be high. This makes it very difficult to closely monitor particularfoods and draw definite conclusions from the research.

You should be aiming for a healthy, balanced diet. Try to aim for a variety of different foods, containing a balance of the major food groups:

• Proteins – for growth and tissue repair.

• Carbohydrates and sugars – for energy.

• Fats – for energy, to absorb certain vitamins and for essential fatty acids.

• Fibre – for healthy digestion.

• Vitamins and minerals – essential nutrients needed for your body to work properly, including tissue repair, bone strength and for absorbing other nutrients.

What foods should I be eating?

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• Fluids – for optimum working of the body. Water carries nutrientsaround the body and is used in the chemical processes happeningin our cells.

The diagram below shows the proportions recommended by thegovernment to balance these food groups, so that you get thenutrients you need. This is often referred to as the ‘Eatwell plate’.

Some nutrients have been researched in relation to MS. On pages5 to 11, we look at: vitamin D (and calcium), vitamin B12, essentialfatty acids and antioxidants.

I can’t help thinking that the only thing we can do is thesame as everyone else, eat a normal healthy balanced diet and hope! If they tell you you’re low on something then get popping those supplements but I’m gonna stickto eating my veggies as my mother ordered. – Mel

Eating nutritionally balanced meals helps the body work to its full potential – particularly useful when living with a long-termcondition. A healthy diet, combined with exercise, can help to:

• maintain healthy weight

• decrease fatigue

Why is it important toeat a balanced diet?

fruit andvegetables

starchycarbohydrates(bread, potatoes,pasta, cereals)

fatty andsugary foodsproteins

(meat, fishand theiralternatives)

dairy

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• maintain regular bowel and bladder function

• reduce the risk of skin problems

• keep bones healthy and strong

• maintain healthy teeth and gums

• strengthen the heart

• improve muscle strength and range of motion

• increase flexibility

• reduce the risk of certain diseases such as heart disease, stroke, osteoporosis and certain cancers

If you are eating a balanced diet then you should be gettingenough vitamins and minerals through your food – and studieshave suggested that this is the best way to get the nutrients you need, rather than through supplements.

But, depending on your circumstances, there may be reasonswhy you might need to take supplements. For example, if yourenergy needs are very low and you don’t eat very much, you may not be getting enough nutrients through your diet. Speak to a health care professional if you think you might need to takesupplements.

If you do take supplements, remember that high doses of certainvitamins can sometimes be harmful. This is because certainvitamins are stored in the body, so they can build up. There’smore information about vitamins and minerals on the NHSChoices website .

Food allergies and intolerances

There’s no conclusive evidence to support excluding specificfoods from your diet to treat MS. But, just like anyone else,people with MS can react to particular foods. If you think youhave an allergy or intolerance, speak to your GP who can helpyou to look into it further. There’s more information about the signs of allergies and intolerances on the NHS Choiceswebsite .i

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What about supplements?

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Your GP can tell you more about healthy eating, and mostsurgeries will have information leaflets you can take home. There’salso more information about getting a healthy diet on the LiveWell section of the NHS Choices website .

You can ask for a referral to a dietitian, who can help if you haveany particular nutritional or energy needs – for example, if youhave a constant tremor, or you’re underweight, or if you haveanother health condition which might affect your diet. A dietitiancan help you plan your meals so that you’re getting all thenutrients you need.

Vitamin D

Vitamin D promotes healthy bone growth and development.Research also indicates that it plays an important role in theimmune system.

Several studies have suggested that vitamin D deficiency plays a role in the risk of developing MS – but it’s not yet clear exactlywhat this might be.

We get most of our vitamin D through exposure to the sun: it ismade by our bodies in reaction to sunlight on our skin. MS ismore common in areas further away from the equator where there is less sunshine. This suggests that there is a relationshipbetween vitamin D and the risk of developing MS.

Some recent research studies suggest that a lack of vitamin D inearly childhood or before birth might increase the risk of developingMS later in life. This is not yet confirmed however, and is thesubject of ongoing research.

At the moment, it’s not clear whether vitamin D plays a role inmanaging MS once it has developed. A number of studies havesuggested that it may help, but more research is needed.

Most people get the majority of their vitamin D from exposure to sunlight. It’s also available (in smaller amounts) in food. Goodfood sources of vitamin D include oily fish, such as salmon andsardines, fortified breakfast cereals and eggs. Small amounts are also found in margarine and full-fat milk. Bear in mind that it is almost impossible to get all the vitamin D you need throughdiet alone.

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What is it needed for?

How might vitamin D be linked with MS?

Who can help with diet and nutrition?

How do I get it into my diet?

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Opinion is divided over how much vitamin D we need, and howmuch sunshine we need in order to make it.

Some people suggest that around 15 minutes of sunlight a day onbare skin during the summer months, along with a balanced diet,is enough to produce enough vitamin D to last through much ofthe winter as well. But this is just an average, and might not besuitable for everyone. For example, it depends how much skin is exposed to the sun – and people with darker skin may wellneed to spend longer in the sun. Your body also can’t producevitamin D when you’re wearing sunscreen, so you should aim for at least a few minutes of sun exposure each day withoutsunscreen – taking care not to burn. Over-exposure could lead to other problems, including skin cancer.

Vitamin D can help to reduce the risk of osteoporosis, so it’simportant to make sure that you’re getting enough – particularly if you’re less mobile, or have taken long courses of steroids.

You should aim to get enough vitamin D through exposure tosunlight and through diet. But there might be times when youneed to consider a supplement – for example, if it’s difficult foryou to get outside. And certain groups of people are advised totake vitamin D supplements. These include women who arepregnant or breastfeeding, and people over 65.

If you’re concerned about your vitamin D levels, you should askyour GP for a blood test. They may need to make a charge forthis service. If you are found to be deficient in vitamin D, they may recommend a supplement.

It’s not yet clear whether vitamin D supplements can actually help with managing MS. Things we don’t yet know include: the levels of vitamin D that might have a beneficial effect onpreventing or treating MS; whether this can be achieved throughsupplementation and if so, what dosage would be needed; at what stage in life this would be beneficial; and whether thedose required is safe.

If you’re considering taking supplements, bear in mind that very high doses may have side effects. These can include abnormallyhigh levels of calcium in the blood.

How much do I need?

Should I takesupplements?

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NHS Choices has more information about sources of vitamin Dand what they consider safe amounts if you use a supplement. If you’re thinking of using a supplement, speak to your GP, MSnurse or dietitian for advice.

Calcium

• What is it needed for?

Calcium is vital for maintaining strong bones, which helps protectagainst osteoporosis. It also regulates muscle contractions, and helps blood to clot normally.

• How do I get it into my diet?

Milk and dairy products – including yoghurt and hard cheesessuch as cheddar and edam – are the richest sources of calcium.Tinned sardines and pilchards (where the bones are eaten), bread (particularly white), tofu, green leafy vegetables, bakedbeans and other pulses, certain nuts and seeds (tahini, almonds,brazil nuts, hazelnuts) plus dried figs are also good sources.Calcium-enriched soya products, such as milk, yoghurts orcheeses, are also available.

Skimmed milk contains as much calcium as full-fat, so you can cut down on fat without losing out on calcium. However, as well as getting plenty of calcium, you should also make sureyou’re getting enough vitamin D, as it helps your body to absorbcalcium. Low fat products contain less vitamin D than full fatversions.

• How much do I need?

The recommended amount of calcium per day is 700 mg. This is the equivalent of about a pint of milk, or two to three portionsof dairy, such as a yoghurt or matchbox sized piece of cheese.

• Should I take supplements?

If you are prescribed a course of steroids – or if you are lessmobile – a health care professional might suggest calciumsupplements to strengthen your bones. If you are concernedyou’re not getting enough calcium or vitamin D then you should talk to your GP about whether you might benefit fromsupplements. To find out if you have enough calcium in yourbones, you would need to have a scan to check bone mineraldensity.

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Vitamin B12

Vitamin B12 has several important functions. It helps to releaseenergy from our food and to process folic acid. It’s also involvedin making red blood cells, and plays an important role in thenervous system.

The relationship between vitamin B12 and MS is complex and not fully understood.

The body needs vitamin B12 to make myelin – the protective layer around nerve fibres that gets damaged in MS. Vitamin B12deficiency can also lead to symptoms similar to MS. Because ofthis, in the past some people have suggested that vitamin B12therapy might play a role in managing MS. However, there is noclear evidence to show that this is the case.

Vitamin B12 is found naturally in animal products, including meat,fish and dairy. It’s also added to some breakfast cereals (knownas ‘fortified’). Yeast extract such as Marmite can be a goodsource if you are vegan.

Most people get enough vitamin B12 in their diet, but somepeople can be deficient. This is more likely if you are vegetarian or vegan.

It’s also believed that some people with MS lack an enzyme toprocess vitamin B12 – meaning that they can be deficient even ifthey include lots of vitamin B12 in their diet. If you’re concernedabout your vitamin B12 levels, speak to your GP who can carryout a blood test.

Research hasn’t shown any benefit in taking supplements if youare not deficient in vitamin B12.

Essential fatty acids

Essential fatty acids (EFAs) are types of fat that the human body needs for good health. You might also hear them calledpolyunsaturated fats, as many polyunsaturated fats in the humandiet are EFAs. There are two main groups of EFAs: omega 3 and omega 6. EFAs are needed for a wide range of normal bodyprocesses.

What is it needed for?

How might vitamin B12 be linked with MS?

How do I get it into my diet?

What are they and whatare they needed for?

Should I takesupplements?

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EFAs play an important role in the central nervous system (the brain and spinal cord). They are needed to produce two hormone-like substances, called prostaglandin E2 andprostaglandin E3. These both play a complex, interactive role in inflammatory and immune responses. EFAs are also needed to make and repair myelin.

Some studies have suggested that omega 6 EFAs may benefitpeople with MS. As a result, linoleic acid (a form of omega 6 EFA) is included in the 2003 NICE guideline for MS, which sets out how MS should be treated on the NHS in England and Wales. It says that 17-23 g of linoleic acid a day may slow theprogression of disability.

But a more recent review of all the evidence relating to EFAsupplements (both omega 3 and omega 6) found that they did not appear to have a major effect on disease progression. Thereview did, however, say there was not enough evidence to reach firm conclusions.

Sources of omega 3 EFAs include:

• oily fish, including sardines, mackerel, salmon and fresh tuna

• certain nuts, seeds and beans including walnuts, linseed and soybeans

Sources of omega 6 EFAs include:

• certain seed and vegetable oils such as sunflower, safflower, soy and corn oil

• food made from the above oils including margarine, saladdressings and mayonnaise

It’s not clear how much of each EFA you need to have in yourdiet, but a good balance of both may be more important than the total amounts of each. They both have to compete for thesame chemicals in the body, so too much of either might limit the effects of the other.

EFAs still contain the same amount of calories as other types of fat so, while they are better for health, it’s best not to eat too much.

More research is needed to find out the ideal intake.

How might EFAs be linked with MS?

How do I get them in my diet?

How much do I need?

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Antioxidants

Oxidants, or free radicals, are chemicals that react easily withother substances in the body, changing or damaging theirstructure. For example, essential fatty acids are vulnerable toattack from oxidants. Certain vitamins – including vitamin A, Cand E – can limit the damage oxidants cause and protect theessential fatty acids. These vitamins are known as antioxidants.

Some research has suggested that oxidant activity in the centralnervous system may be linked to the damage that occurs in MS.However, there have been few studies into the use of antioxidantsfor people with MS and the significance is still unclear.

Theoretically, antioxidant therapy could make the effects of MSworse, as some antioxidants have a stimulating effect on theimmune system – although the levels found in a balanced diet would not cause a problem. More research is needed to determine the safety and potential benefits of antioxidant therapy for MS.

Brightly coloured fruit and vegetables – red, orange, green andyellow – are the best source of antioxidants. Aim for at least five portions a day, choosing a variety of types and colours.

If you are eating a balanced diet then you should be gettingenough antioxidants through your food without the need forsupplements.

If you have difficulty eating fruit and vegetables or if your diet is particularly limited then you should speak to a dietitian aboutwhether you would benefit from taking supplements.

Special diets

I have eaten porridge for breakfast nearly every day for over 20 years and would love to believe that it's the reason why my MS is fairly tame but I know that in reality although porridge is good in many ways it’s not magic. – Daff

What are they needed for?

How might antioxidants be linked with MS?

How do I get them into my diet?

Should I takesupplements?

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Over the years, many special diets have been promoted to help with MS. These include low-fat, allergen-free, gluten-free,pectin-restricted, low-sugar diets, and diets that avoid processed food. As mentioned earlier in this booklet, it is very difficult tocarry out research into diet and MS, so as a result there is verylittle evidence for most of these diets. But what we know aboutMS does not suggest that you need to avoid particular foods.

Following one of these diets is an individual choice – but if you do decide to try a new diet, it’s important to make sure you stillget enough energy and all your essential nutrients. Many peoplewith MS say that following a special diet gives them a feeling ofcontrol over their MS. Some people say their diet makes themfeel better, but that’s not the case for everyone.

As with any other lifestyle change, there are lots of things youmight want to consider before choosing to follow one of thesediets. These include:

• What’s the evidence behind the diet? Does it make extravagantclaims about how it will help your MS? Are these claims backedup by science?

• ‘Personal stories’ are just that – everyone’s MS varies so it isdifficult to know whether a diet improves MS or whether anyimprovement is the result of a period of remission. And what helps someone else will not necessarily help you.

• Food is about more than just basic nutrition. Can you still eat your favourite foods while following the diet? If you enjoy eatingmeals with others – perhaps at home, in restaurants or at otherpeople’s houses – will you still be able to do so?

• Are you getting enough energy from the diet? If you haveincreased energy needs – for example, because of constanttremor or because you are underweight – then if you limit the kind of food you eat you may find you lose weight and becomemalnourished.

• Can you still get a proper balance of all the food groups whilefollowing the diet?

• Many of the diets require you to prepare each meal from freshingredients. Do you have the time, energy and money to do this?Do your MS symptoms affect your ability to prepare food?

What’s the evidence?

Can you still enjoy your food?

Is it good for you?

How practical is it?

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• If you cook for other people, will they be happy to follow the same diet or will you have to cook separate meals? Equally, if someone else usually cooks for you, would they be willing toprepare special meals for you?

• Can you stick to the diet? Many diets place strict restrictions on what you can and can’t eat. You shouldn’t feel guilty if you try to follow the diet but find you’re unable to stick to it.

You should speak to your doctor before making any majorchanges to your diet, particularly if you have any other healthconditions which might also affect your dietary needs.

Some do well on Swank, or Professor Jelinek’s diet, some on Best Bet Diet and there are other diets, all of which will work for someone, somewhere. It's worth a try, but only if you feel you really want to, or else you’ll hate your new diet and cheat wherever possible. The waythat MS manifests itself is so different from person to person, makes it very frustrating to deal with. Wouldn’t it be nice if there was a one-stop fix for all? – Karen

The Swank Diet is perhaps the best known diet associated withMS. It is named after Dr Roy Swank, who developed the diet inthe 1940s. It restricts the amount of fat you can eat: no more than15 g of saturated fat a day, and between 20-50 g of unsaturatedfat. It also limits your intake of red meat and oily fish, although youcan eat as much white fish as you like. The diet also recommendsthat you take cod liver oil and a multi-vitamin and mineralsupplement every day.

Some people say that following this diet has made them feelbetter, and reduced the number of relapses they’ve had. Otherpeople have not had any benefit from following it. Research intothis diet has not definitely proved any benefits. Although a numberof studies have been carried out, they have not generally beenwell designed. They also had very high drop-out rates, so withoutknowing what happened to the people who dropped out of thestudy it is hard to draw clear conclusions. However, following thisor a similar diet would not generally be considered bad for you – and lowering the amount of saturated fat you eat is widelyaccepted as good health advice.

The Swank Diet

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Cutting down on meat and dairy products to reduce yoursaturated fat intake might mean you’re not getting enoughprotein, so you would need to find alternative sources such as fish, beans and pulses. Cod liver oil has a blood thinningeffect, so it should be taken with caution if you take aspirin oranticoagulant medications such as warfarin, or if you have ableeding disorder. Cod liver oil also contains high levels of vitamin A, so you should not take it if you also take supplementscontaining vitamin A, or if you eat liver regularly. If you havediabetes you should speak to your doctor before taking cod liver oil.

This diet can be low in energy, which may cause you to loseweight. If you have high energy needs or if you are alreadyunderweight then it may not be suitable for you.

The Overcoming MS (OMS) programme was developed by Dr George Jelinek in 1999 following his own diagnosis with MS. Itcombines a number of different elements, including diet, exercise,meditation, vitamin D and medication.

The OMS diet recommendations are similar to the Swank diet. It advocates cutting out dairy and meat, and reducing fat intake – particularly saturated fat. It also recommends supplementation,particularly with omega 3 (in the form of fish oil or flaxseed oil)and vitamin D if your exposure to sunlight is limited.

Research into this diet has not provided conclusive evidence of its benefits. Although a five-year follow-up study showed self-reported improvement in physical and mental wellbeing amongparticipants, this has to be weighed against a very high drop-outrate. Without knowing what happened to the people who droppedout of the study, it is impossible to draw firm conclusions aboutthe programme.

However, as with the Swank diet, following the OMS programmeis not likely to be considered bad for you. You should make sureyou’re getting enough protein in your diet, through eating plentyof fish, beans or pulses. Likewise, the diet may be low in energy,so it may not be suitable for you if you have high energy needs or you are already underweight.

Another diet that is claimed to help with MS is the Best Bet Diet,developed by Ashton Embry. This diet recommends avoidingseveral different food types, including all dairy, grains andlegumes (beans and pulses). It also recommends extensivesupplementation, including calcium and vitamin D.

The Overcoming MSprogramme

The Best Bet Diet

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The diet is based on the assumption that partly digested foodprotein can pass through from the intestines into the bloodstream.In this theoretical model, certain food proteins are able to activatethe immune system due to their similarity to immune cells, leadingto the symptoms of MS.

The body of evidence to date does not support this theory, nordoes it suggest there is any benefit to cutting out any of thesefood types completely. This particular diet has not been tested in any research trials, so there is no evidence that it can helpmanage MS symptoms. Like the Swank diet, the Best Bet dietcan be low in energy so it may not be suitable for you if you havehigh energy needs or if you’re already underweight. It also maynot be suitable for vegetarians and vegans, as it cuts out animportant source of protein.

Diet and your MS

I love cooking and always loved entertaining and doing three course meals, but now I think, what can I do that still looks impressive but that will take a lot less energy? It’s the little things for me like how you arrange it, colours, big flavours. – Louisa

You might find that making changes to your diet can help withmanaging specific symptoms – or that your symptoms affect both what and how you eat.

There is more information in the MS Society booklets Managingthe bowel in MS, Managing bladder problems, Swallowingdifficulties, Fatigue, Tremor and Vision and MS.

If you get tired quickly, you might find it easier to eat small,frequent meals and snacks rather than large, hot meals. Try not to rely on sugary foods to keep your energy levels up – althoughthese can have an initial pick-me-up effect, this is often followed by an energy low. Starchy carbohydrates, such as potatoes,bread and pasta (particularly wholemeal), can give you a slowrelease of energy that can keep you going for longer. Try to makesure you eat regularly and include a snack if you have a long gap between meals.

Dehydration can lead to tiredness, so try to keep your fluid intakeup. It doesn’t just have to be water – tea, fruit juice and coffeecan all help you stay hydrated. If you’re particularly tired, it can

Fatigue

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Bladder problems

be tempting to drink lots of caffeine. But these drinks usually onlyhave a temporary effect, and can leave you more tired – althoughthere’s no evidence that moderate amounts of tea or coffee willmake you dehydrated.

If you have bladder problems – particularly problems with urgencyor frequency – then you might be tempted to drink less so youdon’t need to go to the toilet as often. But this can make yoururine more concentrated, which can irritate your bladder andmight make you more likely to get a urinary infection. It helps tokeep up your fluid intake. If you can, aim for about 1.5 to 2 litres(or about six to eight cups) of fluid a day. Although be careful tolimit your alcohol intake, as too much can make you go to thetoilet more often.

If you need to get used to drinking more, it is best to increaseyour fluid intake gradually – on days when you are at home orwhen it is easy to get to a toilet, for example.

Cranberry juice

Cranberry juice or cranberry extract tablets are often promoted as helping to prevent or treat urinary tract infections. Althoughresearch studies have been carried out, there is no conclusiveevidence that they can help people with MS. If you do drinkcranberry juice, remember that fruit juices are high in sugar and can quickly add up to a lot of calories. They can also bedamaging to teeth.

Double vision or blurring might make it harder and more timeconsuming for you to prepare or eat food – and it may seem tolimit your choice. There are some practical solutions that canhelp, which are outlined on page 20.

If you have severe visual problems, you might find it helpful if yourfood is set out in an agreed way. For example, you could ask theperson who prepares your meals to lay out the food as if the platewere a clock face. If the potatoes are placed at ‘12 o’clock’ andmeat at ‘6 o’clock’, this might make it easier for you to find thefood on your plate.

Tremor can affect your nutritional needs, or your approach toeating. If you have constant tremor it uses up calories, whichmight mean that you lose weight. It can also add to fatigue.Adding high-energy supplements to your diet can help. You canalso speak to your GP or MS nurse for advice, and they can referyou to a dietitian if necessary.

Visual problems

Tremor

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If your tremor makes it difficult to hold or reach for things, certainfoods may be easier to eat than others. You may find that fingerfoods, or home-made sandwiches are easier to manage thanstews and soups. They are just as nourishing and can also behigh in calories if you use mayonnaise in the filling. You can alsoget specially designed cutlery, crockery and kitchen utensils thatcan make preparing and eating food more manageable. There’smore information on preparing food on pages 18 to 22.

If you have problems with swallowing – also known as dysphagia– this can make eating more difficult, even distressing. But thereare a number of ways to modify your eating habits or diet thatcan help.

• Small, frequent meals and milky drinks may be easier than largemeals, and can help to make sure you’re still getting enoughcalories.

• If chewing is difficult for you, soften your food beforehand with a fork or blender, and avoid tough or stringy food.

• Thickening agents in drinks can help prevent liquids from goingdown the wrong way. You can get these on prescription from your doctor, along with pre-thickened fruit juices.

There’s more information in the MS Society booklet Swallowingdifficulties. You can also ask your GP for a referral to a speechand language therapist, who can help you to find ways ofmanaging swallowing difficulties.

If you are having great difficulty with chewing or swallowing yourfood, and you are losing weight or becoming dehydrated despitefollowing the tips above, then a direct liquid feeding system maybe helpful. The most common of these is a PEG (percutaneousendoscopic gastronomy) system, in which the food goes directlyinto your stomach through a tube. There is more about a PEGsystem in the MS Society booklet Swallowing difficulties, or youcan contact the charity PINNT .

Changes to your diet are often suggested as the first line oftreatment if you have bowel problems.

If you’re experiencing constipation, keeping up a good fluid intake can help, as can a diet with plenty of fibre. Fibre cannot bedigested and passes straight through the gut, helping digestion of other foods and removal of waste. A well-balanced diet, withplenty of fruit and vegetables, can provide this fibre. Goodsources include prunes (or prune juice), figs, wholemeal bread,fibre-fortified white bread, brown rice, porridge and wholegrainbreakfast cereals.

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Bowel problems

Swallowing difficulties

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Osteoporosis

If incontinence is a problem for you, it is worth experimenting with your diet to see if there are any foods that make it worse, ormake your stools firmer. High-fibre foods, caffeine, milk products,chocolate, alcohol, spicy food and artificial sweeteners can allhave the effect of producing loose stools in some people. If youkeep a food diary for a few days it may help you to identify whichfoods help or make it worse. It may help to do this with the supportof a dietitian, for guidance.

Osteoporosis causes bones to become more fragile and more at risk of breaking. While it’s not a symptom of MS, people withMS might be at a higher risk of developing osteoporosis than the general population. There are a number of possible reasonsfor this:

• long courses of steroids, used to treat relapses

• a lack of weight-bearing exercise (where your feet and legssupport your weight)

• lack of sunlight, perhaps because of heat sensitivity or inability to get out of the house, leading to lower vitamin D intake

People with MS are also at a higher risk of falls and fractures, due to symptoms such as balance problems, so bone health isimportant. Keeping up good levels of vitamin D and calcium, bothfrom your diet and from sunshine, can help to reduce the risk ofosteoporosis, as these both help keep bones strong and healthy.There’s more information about vitamin D and calcium, and howto get them in your diet, on pages 5 and 7.

Although pressure ulcers are not a symptom of MS, you may be at risk of developing one if you are severely affected by MSand spend a lot of time in bed or in a wheelchair. If you areunderweight this can add to the risk, as you lose the naturalpadding over your sitting bones and other bony points. You canspeak to your GP if you, or your carers, are concerned about your weight and your risk of pressure ulcers. A well balanced diet,including foods rich in vitamins and protein, is important if youhave pressure ulcers or are at high risk.

There is more information about pressure ulcers in the MS Societyfactsheet Pressure ulcers.

Pressure ulcers

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Preparing meals

Living with MS might mean it takes longer to go shopping orprepare food. Because of symptoms like fatigue, you may findyou need to plan these everyday tasks more carefully than youdid before. The following tips can help make all stages of preparingmeals a little easier – from planning what to eat to clearing up afterwards.

Most of these tips don’t involve big, obvious changes to what you do – or to your kitchen. It’s all about finding the easy,everyday improvements that work for you.

Occupational therapy

An occupational therapist (OT) can suggest energy-saving tipsand helpful equipment or adaptations to make preparing foodeasier. They can also advise on grants that may be available for adaptations. To arrange an OT assessment, contact your local social services (social work in Scotland) department. YourGP can also make a referral for you. There’s more information about adaptations in the MS Society booklet Adaptations andyour home.

I set myself up a food plan a few months ago, and withdoing a monthly shop I can pretty much plan out 3 or 4weeks’ worth of meals. I know it sounds sad but I actuallyenjoy doing my plan and am quite proud of myself that I’m pretty much sticking to it and am eating so much better because of it. I think it's also good because you can start doing any prep you need to do through the day rather than all when it comes to meal time and tire yourself out less. – Louisa

• Planning a menu for the week can help to cut down on shoppingtrips, and can also make sure that food doesn’t go to waste.

• Cooking double batches and freezing the spare ones meansthere’s always something for you to eat even when you’re notfeeling up to cooking.

• Even if you can’t get to the shops or prepare food, get involved in planning meals for the week ahead. That way you’ll still get toeat the food that you want. This is particularly important if youhave a mix of different people – family, friends and paid carers – who might all be involved in preparing meals for you.

Planning

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• A ‘likes and dislikes’ list can also help to ensure you’re getting a good mix of meals that are to your taste, even if you’re not theone making them. If your MS affects what you can eat, perhapsbecause of swallowing difficulties, you might want to work with a dietitian to compile this list so that you’re still getting all thenutrition you need.

I now do my main food shop online and have it delivered to my home. I find the whole shopping experience verytiring. If the supermarket is very busy, I get quite stressedand sometimes confused. I always would need to plan for a loo stop as well! – Lyndsey

• All the major supermarkets offer a delivery service – which cansave a trip to the shops, or having to carry heavy bags home. Ifyou do your shopping online, you can usually save your regularorder so you don’t have to remember it each time.

• Make a master shopping list of things you regularly buy, and print off multiple copies. Before going to the shops, check the list and tick off the items you’ve run out of. It’s a simple reminderand an energy saver. And if you’re having a bad day with yourMS, someone else can use the same list.

• Delegate tasks – can someone else in your household, or a friend,do the shopping for you?

• If shopping is too difficult, you could ask for an assessment ofyour needs from your local social care services (social work inScotland) department. You might be eligible for help with yourshopping.

Best of all though is my mini chopper/ blender/ liquidiser.Now I can chop an onion without wasting half of it or watching it bounce across the floor several times. I also have a gadget which opens jars and bottles and it is a godsend. Am I also allowed to mention my son?Because if he is around I just hand jars or bottles to him! – Tracey

• Before starting to cook, gather everything you’ll need together, to avoid moving around more than you need to.

Shopping

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• Some tasks can be done just as well sitting as standing.Overhanging worktops can often be fitted to kitchens to makethis easier. Height adjustable stools and stools with sloping seats(perching stools) can make getting up and down easier.

• Adaptations to your kitchen could make things easier. Forexample, if you have problems with balance, grab rails can befitted to many kitchen units and walls. Or you could arrange thespace so the table where you eat is close to where you prepareyour food. For more on adaptations and sources of funding, seethe MS Society booklet Adaptations and your home.

• Using a microwave means you don’t have to lift heavy pans. Theycan also help if heat makes your symptoms worse, as they don’twarm the kitchen while cooking. Induction hotplates also warmthe pans without heating the air around them.

• Can someone else help you? If you live with others, you couldshare tasks. Or you could take it in turns to cook, so you don’thave to do it every day.

• There are gadgets that can help with almost every daily task inthe kitchen. Some ideas include:

– If you find it difficult to grip things or handle them: jar andring pull openers; easy grip handles on cutlery, peelers andother utensils; two-handed cups; non-slip chopping boards; tap turners (large handles to fit over existing taps); and knobturners (to help with fiddly controls on cookers and otherkitchen equipment).

– If you find it hard to lift things: cooking baskets, so you can lift food in and out of pans, rather than lifting the whole pan; a wheeled trolley to move items around the kitchen rather thancarrying them; and a kettle tipper, so you can pour it withoutlifting it.

– If you have visual problems: large controls and displays oncookers, microwaves, timers and weighing scales; speakingscales; coloured tape around worktops to provide a contrast;and brightly coloured chopping boards, cutlery and utensils to make them easier to spot.

For more ideas and for further information, contact the DisabledLiving Foundation, Ricability or the RNIB .

• If preparing food is difficult or tiring:

– Ready meals can be a practical alternative. However, they canbe low in protein and high in salt so they may not be suitable for every day. Choose ones labelled ‘low fat’ or ‘healthy eating’unless you are underweight. If you find yourself relying on them,

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Weight loss

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you can ask your GP for a referral to a dietitian who can helpyou to find easy-to-prepare alternatives.

– You might be able to get ‘meals on wheels’ delivered directly to your door. Many areas offer this service as part of a carepackage from social care services (social work in Scotland).Contact them for an assessment of your needs, to see if you are eligible.

– If you cannot prepare a cooked main meal for yourself if youhave the ingredients, then you might be eligible for DisabilityLiving Allowance. For more information, see the MS Societybooklet Claiming Disability Living Allowance.

I leave plates and pans to soak, as often I can’t wash up straight away. Then they are a lot easier to wash as well. – Carole

• Dishwashers can make washing the dishes less tiring. But theyare not great for everyone, as they still need to be filled andemptied.

• If you live with others, share the tasks with them – so if youcooked, ask someone else to clear up.

Managing your weight

I found that telling everyone I was trying to lose weight was a good motivator as people kept asking me how I was doing, but not in a nagging way, and it feels good to be able to say I was losing weight, and this took overfrom people asking how my MS was! – Anon

Living with MS can sometimes make it harder to manage yourweight, and both weight loss and weight gain can be a problem.

Problems with posture, swallowing, fatigue and tremor can all make shopping for, preparing or eating food more difficult. And your appetite can also be affected by stress, anxiety and depression, as well as certain drug treatments. If you are affected in any of these ways, you might find you lose weight.

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If left untreated, weight loss can lead to malnutrition. You may not notice this at first, as the early signs of malnutrition – fatigueand muscle weakness – can also be symptoms of MS. If you findthat you’re losing a lot of weight, or you’re already underweight,speak to your GP. There are ways to treat the issues that might be causing you to lose weight.

If you find it difficult to get enough energy and nutrients, your GP may suggest that you see a dietitian. They can advise you onways to get more nutrients and energy into your diet. Sometimeshigh energy supplements are recommended. These are availableeither over the counter or on prescription and should be takenbetween meals. If you do use them, bear in mind that they often have high sugar content so it’s important to visit the dentistregularly (see our factsheet Oral health and MS for more on this).

Keeping generally fit and healthy can make it easier to cope withthe symptoms of MS. But having MS may mean you are less activethan you once were, so you may find you are putting on weight.

Certain drug treatments, including steroids to treat relapses, canalso lead to weight gain. And if you’re drinking lots of fruit juices or sugary drinks to increase your fluid intake, this will also increaseyour calorie intake. Stress, anxiety and depression can lead somepeople to comfort eat. Doing this occasionally is not a problem,but if you find you’re doing it a lot then you will put on weight. If you think your comfort eating is due to depression, you shouldspeak to your GP as depression is treatable. There’s moreinformation on the signs of depression in the MS Society bookletMood, depression and emotions.

Following general healthy eating advice, as well as getting regularexercise, should help you to lose weight. Avoid crash dieting tolose weight quickly, and instead aim to lose around 1-2 pounds, or half to one kilogram, a week. However, if your mobility islimited and you can’t be active, you may find your weight reducesmore slowly. If you have put on a lot of weight, then you maywant to speak to your GP about the best way for you to lose the weight and still get all the nutrition you need. There is alsoinformation about exercise and MS in the MS Society bookletExercise and physiotherapy.

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Read more

Our free booklets help explain MS, look at its practical andemotional effects, and help you find your own ways to manage life with MS. Titles are available in large print, audio format and a number of languages.

We can help you find and borrow other books, research articlesand DVDs about living with MS. Search online or call the UKInformation Team.

Find out more online

Get the latest on research, campaigns and MS news. Chat onlinewith our message boards and Facebook. Follow us on Twitter, see the MS community at Flickr and watch us on YouTube.Children and teenagers can find out more and link up through our YoungMS site: www.youngms.org.uk

Join us

Receive local and national news, and get involved locally andnationally. Be as involved as you like. Just by being a member you strengthen the voice of all people with MS, and help us continue our vital work. Join online, or call 020 8438 0759 or your national office.

Get in touch

The freephone MS Helpline offers confidential emotional supportand information for anyone affected by MS, including family, friendsand carers. Information is available in over 150 languages throughan interpreter service: 0808 800 8000 (weekdays 9am-9pm) orhelpline@mssociety.org.uk. Contact the UK Information Team oryour national office if you have any questions about MS.

Near you

Our volunteers run over 300 local branches and support groups.They provide information about MS and local services, and a chance to meet others affected by MS and take part in a range of activities.

In many parts of the country, you can pick up our booklets at MSSociety Info Points. Larger information centres – including ones in our national offices in London, Belfast, Cardiff and Edinburgh(Newbridge) – can help you with information about MS and services in your area.

Or come along to our local and national events and learn moreabout MS from expert care professionals, researchers and otherpeople with the condition. Find out more online or call your national office.

FurtherinformationUK Information Team 020 8438 0799infoteam@mssociety.org.ukNational offices – see back coverwww.mssociety.org.uk

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Further reading

The MS Society library has a number of books on diet andnutrition available to borrow. Some of these are listed below. To borrow them, or to find out what other books are available,contact the librarian: call 020 8438 0900, emaillibrarian@mssociety.org.uk or go to www.mssociety.org.uk/library

Cooking well: multiple sclerosis, by Marie-Annick Courtier.Published by Hatherleigh Press (2009), ISBN: 9781578263011.

I-Can’t-Chew-Cookbook. Delicious soft-food recipes forpeople with chewing, swallowing and dry-mouth disorders, by J Randy Wilson. Published by Hunter House Publishers (2003), ISBN: 0897934008. This book contains recipes for a widevariety of meals and includes nutritional information for each one.As this is an American book, the measurements for recipes maydiffer from UK scales.

Recipe collection: easy-to-swallow meals. Produced andpublished by the Motor Neurone Disease Association. Contains a range of meals to suit people with swallowing difficulties.Available for a charge of £5 + P&P from the MND Association:telephone 08457 626262 or write to MND Association, PO Box246, Northampton NN1 2PR.

Dietary supplements and multiple sclerosis: a healthprofessional’s guide, by Allen C Bowling and Thomas M Stewart. Published by Demos Medical Publishing (2004), ISBN: 1888799900. Aimed at health professionals, this booksummarises the research behind a range of dietary supplements.

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Useful organisations

Disabled Living Foundation (DLF)

Can provide information and advice on equipment that might help with preparing and eating food.

380-384 Harrow RoadLondon W9 2HU

Helpline 0845 130 9177Textphone 020 7432 8009www.dlf.org.uk

NHS Choices

The Live Well section has information on all aspects of healthyliving, including diet and nutrition.

www.nhs.uk/livewell

PINNT – Patients on Intravenous and Nasogastric Nutrition Therapy

Provides information and support for anyone using PEG or other feeding systems.

PO Box 3126ChristchurchDorset BH23 2XS

www.pinnt.com

Ricability

Researches and publishes consumer reports on products andservices of interest to disabled people. Reports include kitchendesign and appliances.

Unit G03The Wenlock Business Centre50-52 Wharf RoadLondon N1 7EU

Telephone 020 7427 2460Textphone 020 7427 2469www.ricability.org.uk

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RNIB

Offers information and support for people with sight problems.

105 Judd StreetLondon WC1H 9NE

Helpline 0303 123 9999www.rnib.org.uk

References

A list of references is available on request, and all cited articlesare available to borrow from the MS Society library (there may be a small charge). Contact the UK Information Team, or visitwww.mssociety.org.uk/library

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Authors and contributors

This edition written by Jude Burke

With thanks to: Bernice Chiswell, Dr Olga Ciccarelli, SharonGrainger, Alison Johnson, Liz Joslin, Lynn Miller, Dr Anne Payne,and all the people with MS who contributed to this publication.

Disclaimer: We have made every effort to ensure that informationin this publication is correct. We do not accept liability for anyerrors or omissions, and policy and practice may change. Seekadvice from the sources listed.

Suggestions for improvement in future editions are welcomed.Please send them to infoteam@mssociety.org.uk

© Multiple Sclerosis Society 2012

First edition, September 2006

Fourth edition, August 2012

This title will be reviewed within two years of publication.

The MS Society provides this information free of charge but if you would like to help cover the cost, which will help towards our essential work, please call 0800 100 133 or visit the fundraising section of our website to make a donation. Anything you can give will be greatly appreciated.

MS SocietyMultiple sclerosis (MS) is the most common disabling neurological disorder affecting young adults and we estimate that around 100,000 people in the UK have MS. MS is the result of damage to myelin – the protective sheath surrounding nervefibres of the central nervous system. This damage interferes with messages between the brain and other parts of the body.

For some people, MS is characterised by periods of relapse and remission while, for others, it has a progressive pattern. For everyone, it makes life unpredictable.

The MS Society is the UK’s largest charity dedicated to supportingeveryone whose life is touched by MS. We provide a freephone MS Helpline; grants for home adaptations, respite care and mobilityaids; education and training; support for specialist MS nurses; and a wide range of information.

Local branches cater for people of all ages and interests and are run by people with direct experience of MS.

The MS Society also funds over 60 vital MS research projects in the UK.

Membership is open to people with MS, their families, carers, friends and supporters. You can help the work of the MS Society by:

• becoming a member• making a donation• offering your time as a volunteer

Contact informationMS National Centre372 Edgware RoadLondon NW2 6NDTelephone 020 8438 0700info@mssociety.org.uk

MS Society ScotlandNational Office, Ratho Park 88 Glasgow Road Ratho StationNewbridge EH28 8PPTelephone 0131 335 4050msscotland@mssociety.org.uk

MS Society Northern IrelandThe Resource Centre34 Annadale AvenueBelfast BT7 3JJTelephone 028 9080 2802 information@mssociety.org.uk

MS Society CymruTemple CourtCathedral RoadCardiff CF11 9HATelephone 029 2078 6676mscymru@mssociety.org.uk

National MS Helpline Freephone 0808 800 8000 (weekdays 9am-9pm) www.mssociety.org.uk

Multiple Sclerosis Society.Registered charity nos 1139257 / SC041990. Registered as a limited company in England and Wales 07451571.

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