This document provides information about swallowing difficulties in multiple sclerosis (MS) and nutrition management for MS. It discusses how MS can damage the central nervous system and disrupt message signaling, potentially causing swallowing problems over time. Symptoms of swallowing difficulties are described. The document recommends good posture and chewing thoroughly when eating, as well as modifying food textures if needed. It notes the risks of weight loss or dehydration from swallowing problems and discusses enteral feeding options. The document also summarizes several MS diets and the limited evidence supporting their benefits, as well as the potential anti-inflammatory effects of omega-3 fatty acids. Overall health, nutrition, weight management, meal planning and food preparation tips are provided.

1. Presented By:
Anahita Dehbozorgi RD
18/09/13
Chelsea & Westminster Hospital

2.  MS – Condition of central nervous system (degenerative)
 Damage to nerve fibres (myelin)
 Partial or complete (lesions or plaques)
 Disruption/delays in message signaling leading to  disability over time
 Symptoms:
Physical: vision problems, balance/dizziness, fatigue, stiffness/spasm,
bowel/bladder problems, speech/swallowing difficulties, tremors
Memory/thinking/emotions: difficulty remembering recent events, problem
solving

3.  Swallowing difficulties - damage to any part of the brain that
controls swallowing, or the connections between the brain and the
spinal cord ‘brainstem’
 May come and go, can happen during a relapse & improve, or
disappear completely
 Swallowing problems may include:
1. Changes in your speech
2. Problems chewing
3. Food sticking in your throat
4. Food or drink coming back up
5. Sluggish movement of food going down, or difficulty moving food back
through your mouth
6. Coughing and spluttering during and after eating
7. Excessive saliva, which may cause dribbling

4.  Good posture when eating & drinking – stay upright 30mins
after each meal
 Relaxed atmosphere
 Eat slowly
 Chew well
 Alternate liquid with solid – keep food moist
 Avoid speaking when eating
 Severe swallowing difficulties: texture modified
diets/nutritional supplements/NG and PEG feeds

5. Following a swallow Ax by speech and language therapies, you
may need the texture of your food and drinks to be modified
 You may require:
Pureed/Fork mashable/ Soft meals
Thickened Fluids such as syrup thick/custard thick

6.  Weight loss or dehydration - 2ndry to swallowing difficulties
 Unsafe swallow ,  risk of aspiration
 ONS (Oral Nutrition Support) may be indicated – if tolerating OI
 Short term (<3-4 weeks) ‘nasogastric tube feeding’ - Liquid food
passes through a very thin tube through the nose and into the
stomach
 Long term: Percutaneous endoscopic gastrostomy (PEG/RIG)–
liquid diet to go directly through a tube into the stomach

7.  Nutritionally balanced meals helps the body work to its full
potential
 poor growth
 poor development
 poor physical and mental health
 infections
 disease
 or even death
 Vit supplements - not required if a balanced diet consumed

8.  ? Reduce relapse rate or improve quality of life
 No conclusive evidence to suggest effectiveness
 Include:
Swank diet,
Best Bet diet and
George Jelinek's Overcoming MS programme

9.  Developed in 1940s, known as ‘low fat diet’
  Fat intake to no more than 15g of saturated fat/day,
and between 20-50g of unsaturated fat
  Intake of red meat and oily fish,  white fish
 Caution:  Meat and dairy foods to reduce saturated
fats  a shortfall in protein
 Research – number of studies (high drop outs) shown
no benefits of diet

10.  Developed by Dr George Jelinek in 1999
 Combines a number of different elements; diet,
exercise, meditation, Vit D & medication
 Similar to Swank diet:  saturated fat +
supplementation of Omega 3 (in the form of fish oil
or flaxseed oil) + vitamin D if limited exposure to
sunlight
 Research – no conclusive evidence of its benefits

11.  2 main components:
1. Avoiding potential “problem” foods
2. Taking vitamin, mineral and herbal supplements
 To avoid any foods with proteins that resemble those in myelin
that are attacked by the immune system
o Dairy: Avoid all animal milk, all butters, cheeses, yoghurt and
any products that contain them
o Gluten: Avoid all wheat, rye and barley
o Legumes: Avoid all beans, peas, peanuts, soybean
o Refined Sugar: This is also avoided because of general
inflammatory properties, with the suggestion of using other
sweeteners instead, such as honey, maple syrup
o Eggs: The idea here is to limit, rather than strictly cut out
o Yeast: limited quantities are allowed
 Research – no conclusive evidence of its benefits

12.  Some studies - low levels of omega-3 fatty acids were
found in people with MS
 Decrease certain immune reactions, reducing
inflammatory responses
 In very small studies of 10 and 16 participants,
omega-3 supplementation  relapse rate & improved
expanded disability status scale (EDSS) score
 In a larger placebo-controlled study (1989)  relapse
& disability progression but results not statistically
sig.

13.  Dietary sources:
 Flaxseeds and flaxseed oil
 Nuts, such as walnuts
 Avocados
 Fatty fish, such as salmon, tuna, mackerel,
sardines, anchovies
 Dark, leafy greens (such as kale, spinach)

14. Side Effects:
 >3 grams/day
o Increased risk of bleeding complications
o Gastrointestinal symptoms
o Increased LDL cholesterol levels
o Elevated blood sugar in patients with diabetes
(although in normal dosages, blood sugar levels
are lowered slightly in healthy people)

15. Aim for a healthy, balanced diet including all major
food groups:
 Proteins – for growth and tissue repair
 Carbohydrates and sugars – for energy
 Fats – to absorb certain vitamins and for essential
fatty acids
 Fibre – for healthy digestion
 Vitamins and minerals; tissue repair, bone strength
and the absorption of other nutrient
 Fluids –carries nutrients around the body

17.  Help control weight
 Decrease fatigue
 Maintain regular bowel and bladder function
 Keep teeth/gum & bones healthy and strong
 Improve muscle strength and range of motion
 Increase flexibility
 Reduce the risk of certain diseases such as heart disease,
stroke, osteoporosis and certain cancers

18.  Weight loss   risk of malnutrition & muscle
weakness
 Contributing factors:
o Posture/swallowing/fatigue/tremors
o Reduced appetite
o Stress & anxiety
o Depression

19.  Weight gain   difficulty mobilizing/co morbidities
 Contributing factors:
o Medication such as steroids
o High intake of sugary drinks/fruit juices
o Stress & anxiety – comfort eating
o Depression

20. WHO Classification BMI Risk of Death
Underweight Below 18.5 Low
Healthy weight 18.5-24.9 Average
Overweight (grade 1 obesity) 25.0-29.9 Mild increase
Obese (grade 2 obesity) 30.0-39.0 Moderate/severe
Morbid/severe obesity(grade
3)
40.0 and above Very severe
World Health Organisation. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO,
1997 [3]

22.  Planning:
Planning a menu for the week to reduce shopping
trips, and reduce food wastage
Cooking double batches and freezing
 A ‘likes and dislikes’ list to ensure you’re getting a
good mix of meals that are to your taste

23.  Shopping:
Shop online as all the major supermarkets offer a
delivery service
Make a master shopping list of things you regularly
buy, and print off multiple copies. And if you’re
having a bad day with your MS, someone else can
use the same list.
Delegate tasks – can someone else in your
household, or a friend, do the shopping for you

24.  Preparing food:
Before cooking – gather all ingredients needed
 Clearing up:
 Use a dishwasher if possible
Share tasks with others

25. Thank you for listening
Any questions?