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    17-01

The Multiple Sclerosis Diet Book


Introduction

p.xi

In August 1948 Dr. Wilder Penfield, then director of the Montreal Neurological Institute, invited me to undertake the study of Multiple Sclerosis. My knowledge of MS changed rapidly, as I interviewed and examined many patients at the clinic, and spent hours in the library. Three useful clues to the disease came to light:

  1. In many cases relapses occured quite suddenly, suggesting a Vascular cause

  2. The Neurological literature suggested that the frequency of the condition varied geographically

  3. Post WW II nutritional studies revealed a marked variation in fat consumption in different parts of the world
    • - suggesting a possible correlation between, high fat intake, and a high frequency of Multiple Sclerosis

p.xii

In the laboratory it was shown that high fat meals caused the blood cells to aggregate or clump, seemingly thus to obstruct the circulation, reduce the Oxygen supply to tissues, and alter the function of the Brain, Heart, and other organs.

This led to the observation that paraffin particles (Emboli), about the size of aggregates, introduced into the bloodstream produced DeMyelinated lesions in the Brain not unlike those seen in MS, and also scattered focal breakdown of the Blood-Brain Barrier.

Larger particles caused lesions of a more destructive type in the Gray Matter. Meanwhile we studied the blood protein changes in patients with MS and the effects of fat meals on blood Plasma proteins.

Because of the observation that fat meals lead to the clumbing of red blood cells in animals and man and that similar clumping occurs in MSers, an instrument known as the screen filtration pressure machine was developed for measuring, the presence in the blood of aggregated blood elements.

By accident, this led to the discovery of aggregated Platelets and Leukocytes in blood that had been stored for transfusion, and to aggregates composed of the same blood elements, during very low blood pressure that resulted from rapid bleeding.

p.xii

These studies were done first on animals, but were later confirmed elsewhere on humans at the time of the Vietnam war. These aggregates were sufficiently large and numerous enough to obstruct the small Blood Vessels and cause pathological and physiological abnormalaties.

p.xiii

By chance, it was found that these aggregates could be removed by passing blood through a layer of polyester wool. In 1961, we were able to show that removal of these aggregates from the blood by filtration improved the circulation, the metabolism, and the function of perfused, isolated organs.

A polyester wool filter of the Heart-Lung machine used during CardioVascular surgery was the next step followed by the transfusion filter. Both filters have been very extensively tested on both animals and humans.

The results of these tests indicate that removal of the aggregates from circulating blood tends to normalize the blood flow, allowing the maintenance of normal Oxygen and Carbon Dioxide contents, in blood and minimize tissue damage.

Needless to say, many patients have benefited. In recent years we have concentrated on the nature of the destruction of small Blood Vessels and surrounding tissues that is produced by these Platelet/Leukocyte Emboli.

The Emboli not only block Blood Vessels, but also erode away the Blood Vessel inner lining (Endothelium) and destroy the surrounding tissues, primarily in the Lung, and also in the Kidney, Liver and Brain.

When the Emboli are removed by filtration, these deleterious changes do not occur. Our next interest will center on the nature of surface membranes of the cellular elements in the circulating blood.

These efforts have been directed to explaining the lesions of Multiple Sclerosis, as well as Heart Disease and Stroke, on a Vascular basis due to Embolic occusion of Blood Vessels by aggregated blood cels.

These studies are reviewed in this book, along with the work of many other researchers, to give the reader an opportunity to view the results and possible progress in this field.

Our patients wanted not only to participate in our studies, but also to know what was happening in our research. One of the aims of this book is to make this knowledge available to many patients, their friends, and their relatives.

p.xiv

It has been our intent to give the patient a more complete understanding of Multiple Sclerosis, its history, nature, and possible causes as well as therapy.

In addition, we would like to bring into stronger focus the rationale for the use of low fat diets, in Heart Disease and Stroke.

We offer the low fat diet to those with Multiple Sclerosis, Heart Disease, or Stroke with the belief that it will benefit them. For others we suggest it as a means of enriching their lives through increased energy and possibly increased longevity.


A Legacy Of Fats And Oils

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p 3

The diagnosis of a disabling disease necessitates a considerable reassessment of one's life and goals, as well as an adjustment of everyday patterns of living.

If the diagnosis is made shortly after onset of the disease, as it usually is with Heart Disease and Stroke, the patient soon develops a sense of security in the knowledge that he or she will at least have some positive guidance, and that all known therapeutic agents will be made available.

On the other hand, if several years elapse between the onset of the disease and the formulation of a diagnosis, as frequently happens in MS, the patient usually experiences severe frustrations and anxieties.

As the symptoms wax and wane, he or she comes to believe that the doctors are either incompetent or are withholding the diagnosis. It is only natural that the patient imagines all sorts of horrible things and that anxiety and even agitation may result.

When the diagnosis of MS is finally made, the patient experiences a sense of relief. He or she can now make plans for the future and is able to seek more expert guidance.

To obtain maximum benifit from treatment, we advocate its application as early as possible. In Multiple Sclerosis this is while the symptoms are transient, in Heart Disease and Stroke before a major disabling attack.

p 4

A change of life style from a diet of high-fat food to one with low-saturated fats and an increase in PolyUnsaturated Oil is strongly recommended.

This should be accompanied by adequate rest, a reduction of stress, and the adoption of a mental attitude that fosters optimism and a determination to live a satisfying life within the limitations of the disease.

The goal of the MSer is to reduce the attacks and promote a state of remission that will add years of fruitful activity to his or her life. It is our belief that the Swank low-fat diet plays a major role in accomplishing this.


Multiple Sclerosis: General Information

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p22

Personal Characteristics

With few exceptions Multiple Sclerosis patients before becoming disabled are intelligent and vital individuals. Physically they are of average height and weight, and athletic in build and inclination. They are usually attractive. They are nervous (tense) and perceptive.

As the disease progresses, the "inbuilt" nervous tension increases and they become irritable. They rarely lose their inclination to work and produce, unless severely disabled.

In general, they become very well informed about MS, through reading and discussions with one another. It is, therefore, very difficult if not impossible, to keep information concerning MS from them.

These characteristics are so frequently observed in the MSer that their absence in the early phase of the disease, should cause one to reexamine the history, for clues to another diagnosis.

Most patients have cold feet and hands, and they are often cold in a warm room. Some may also have spells of being overheated and many experience night sweats. They bruise easily and often suffer from multiple subcutaneous Hemmorrhages for no known reason.

Effects Of Stress

p23

Patients with established MS, withstand both psychological and physical stress poorly. In the face of anxiety or nervous tension, whatever the cause, patients note fatigue and a reduced ability to perform.

The news of a death in the family, continuing domestic and marital difficulties, loss or threatened loss of the means of financial support, and accidents of a freightening nature are frequently followed by increased disability.

Totally new symptoms are not produced by these stimuli as a rule, but exacerbation of existing systems is common. Such aggravations may last a short time and pass completely.

Sometimes the additional disability is prolonged or permanent. Physical stress or fatigue, particularly when deleterious to patients. Probably a combination of the above stresses explains the high frequency of deep fatigue.

Intolerance To Heat

Patients also have a very low tolerance for heat. The onset of hot and humid weather, or a hot bath, leaves many patients with marked fatigue and increased disability that is usually temporary but can be permanent.

Total immersion of the patient or immersion of an extremity in hot water is followed by an elevation of skin temperature of non-immersed as well as immersed parts of the body, and subsequently by fatigue and increased Neurological disability.

A tourniquet on the immersed extremity, to prevent blood from circulating to and from the immersed part of the body, is said to prevent this.

Immersion of subjects in cold water while they are still suffering the effects of earlier immersion in hot water may quickly remove the disability. We have patients who report marked, though temporary, improvement after a cold bath or a swim in cold water.

Recent studies have shown that the temporary improvement of the patient upon cooling occurs if there is a drop in body temperature of at least 0.6 to 1.2 degrees F.

We feel this degree of temperature change is not necessary since,we often observe improvement in patients who have had only their hands in cold water for a few minutes.

p24

Intolerance To Weather Changes

Our studies have shown that about 5% of attacks occured several days after a weather temperature change of more than 20 degrees F. up or down in a single day. These attacks were usually not severe.

The absolute temperature, wind velocity or direction, precipitation, amount of sunshine, barometric pressure, and other factors seemed not to influence the disease.

Temperature fluctuations are probably the reason for the seasonal variation in the well-being of MSers, twice a year, usually during October and November, and in April and May.

At these times of changing weather, patients experience more than the expected number of exacerbations, fluctuations, or fatigue spells.

Seizures

Grand Mal Seizures are rarely seen in MS. In our own cases they have occured in about 3/1,000 patients. However, mild focal Seizures of short duration and short confusional or "absence" type seizures have occured in well over 5% of our patients.

These Seizures keep recurring, sometimes frequently for three to six months, then disappear. In most cases they are completely controlled by therapy with Dilantin. In some cases Phenobarbital has been effective.

AntiSeizure therapy usually can be discontinued slowly after six months without recurrence of the Seizures. ElectroEnCephalograms have not been helpful in recognizing these brief Seizures.

p24

Headache/Migraines

Scintillating Scotoma (Focal Impaired Vision), with or without Migraine Headaches, nausa, and vomiting have been observed frequently. These Symptoms were recorded in eight (10%) of eighty consecutive new patients seen during the first half of 1975.

On treatment of MS with the low-fat diet, these headaches usually become much less frequent and less severe, and they often disappear after one or two years.

p25

Headaches from tension, starting usually in the back of the head and neck and radiating to the back of one or both Eyes, also occur and are usually relieved by mild sedation and the reassurance that comes as the patient improves.

Blood Pressure/Hypertension/Diabetes/Hypo & HyperThyroidism

Hypertension is rare, most patients having decidedly low blood pressure. Diabetes has been a rare complication, although it is common for MSers to have a slightly elevated blood sugar curve (but not abnormally elevated).

There seems to be a tendency for a family history of Diabetes. Both hypo & HyperThyroidism are rare. Because of the patient's weakness, a clinical diagnosis of HypoThyroidism is often made early but is not supported by laboratory evidence.

Sexual Problems

Partial or complete loss of potency in males, which cannot be alleviated by hormones, and a loss of sexual interest (drive) in females occurs, sometimes early, but usually later during disability.

Irregular or absent Menes, is a frequent complication of MS. These symptoms may develop early or late and are usually accompanied by fatigue. In many cases, potency, sex drive, and normal menstration return after recovering from fatigue - usually after a long rest.

Genetic Considerations

Familial cases (presence of MS in one or more brothers or sisters of a patient) were not considered seriously until the early 1930's. It was then noted that a sibling of a MSer was twenty times more likely to have the disease than someone not related.

Subsequent studies in the late 1940's, 1950's and again in 1981 found the familial incidence of MS to be about eighteen times greater than the occurance of MS in the general population, and to involve second and third degree relatives (two and three generations removed) as well as first.

p26

Four to six percent of the patients' blood relatives were found to have the disease. The incidence in children of MSers may be slightly lower than that observed among brothers and sisters. From these observations it seems likely that genetic factors exert their influence on MSers.

One should not forget, that members of families are subject to similar diets and other enviromental influences. It is therefore possible that the suspected genetic factors are less important than they appear.

Extensive studies of MSers with identical twins have revealed that in about 80%, only one member of each pair developed MS. We have observed five such pairs for up to 26 yrs. and only one of each pair developed MS.

p26

Wives and husbands of MSers have rarely developed the disease. In our own thirty-six year experience with continued observation of more than two thousand cases for ten to thirty-six years.

And a total experience of about thirty-five hundred cases, no husband or wife of a MSer has ever developed the disease, nor has any of their children.

Keep in mind that we insist that the entire family be placed on the same low-fat diet whenever possible.

Racial Considerations

It is still not understood how or why racial differences influence the frequency of MS. The prevalence of the disease in greater New York City has been shown to be about the same for all racial groups (about 6/10,000).

One exception was a very low prevalance in poor African-Americans (1.4/10,000). This could be due to their tendency to consume more cereals and less meat and other fat foods than do more affluent segments of our populations. But, one cannot dismiss a possible racial difference.

Recently it was shown that Japanese Americans have a higher rate of MS than is known to occur in Japan. Even so, the frequency of cases among Japanese Americans is still well below that of European Americans living in same areas.

Our observation of Japanese Americans in the Pacific Northwest is that they tend to consume a diet not totally different from the diet of their Japanese ancestors.

p27

Latitudinal Influence

For many years it has been postulated that the frequency of MS was determined by latitude. The further one lived from the equator, the nearer to the colder areas of the world, the greater the risk of acquiring the disease.

A casual survey of the prevalence data would appear to bear this out. However, when analyzed carefully, several studies indicate that such a relationship is misleading.

The first of these in Switzerland showed a change from very high to very low frequency of MS in the very short distance from northern to southern Switzerland (less than 1 degree latitude change).

The second, in Norway showed a very low frequency of MS along the entire coast from near the Artic Circle south through 13 degrees of latitude to well inside the temperate zone.

A study in Japan revealed the frequency of MS to be very low in two areas, one in the far northern part of the country and another in the near southern most part. The northern area is relatively cold; the southern, warm. They are separated by 10 degrees of latitude.

These particular observations indicate that latitude plays little if any part in the causation of MS or in its frequency of occurance. This conclusion is supported by a recent statistical study of geography and nutrition in relation to Multiple Sclerosis.

Frequency Of MS In Males & Females

p27

In our Norwegian study, the new cases of MS that developed each year were split evenly between males and females.

However, this ratio could have been altered by the long duration of the disease (approximately twenty-five years), and because the disease usually treats males less kindly than females. As a result there are present in the MS population more females than males in the ratio of 3:2.

This is probably related to the greater stress, to which males are subjected; plus less opportunity to rest when fatigued. This difference in prevalence of MS is reflected in our thirty-six year study of MS.

Memory & Mentally Related Functions

p29

Impairment of memory, primarily for recent events, develops in many patients slowly and insidiously. The degree of loss usually parallels the general Neurological involvement, but may be more or less severe.

Later in the disease memory loss may interfere with function and judgement in some patients. Stress, anxiety, fatigue, fever, and overheating usually intensify the memory loss and often lead to mild to severe confusion that is temporary but may be sufficient to interfere with work or schooling.

Patients may experience temporary confusion of varying degrees during an exacerbation, even if they have not experienced stress or fatigue.

Age Of Onset Of Multiple Sclerosis

MS is considered a disease of young adults. About 85% of cases have their first Neurological Symptoms between the ages of twenty to thirty-five, although a diagnosis may be delayed for years.

Most of the remaining cases develop before the age of fifty, but an onset in the fifties or even the sixties is not outside our experience. Less than 1% of our cases have had onset between the ages of fifteen and twenty, and we have rarely seen cases with earlier onsets.


Multiple Sclerosis: The Clinical Picture

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p30

The diagnosis of MS should be made as early as possible and the low-fat diet started immediately. If the diet is continued, it will prevent disability in a majority of patients.

Once permanent disability has developed, one can expect to do no more than "hold the line", or more likely to slow down the rate of progress of the disease.

For these reasons this chapter is devoted to a description of the unfolding of the clinical picture.

Particular attention will be paid to the early symptoms. We will consider three periods: the Prodromal, Early, and Late Phases of the disease.


The Prodromal Symptoms

The prodromal period is characterized by vague symptoms without clear-cut Neurological Signs. It is during this period that patients first consult their family doctor and for the first time are referred to a neuroligist.

Neither physican as a rule recognizes the significance of the symptoms and judging from our experience, more than half of the patients with MS are at first considered to have a nonorganic psychiatric disese.

p31

At some point they may be referred to psychiatrists, who usually agree with the referring doctor's diagnosis. The patients are usually unhappy because their complaints are not taken seriously.

Consequently, the advice of other doctors is sought. Repetition of this series of events results in frustration, anger, and resentment.

These very early symptoms are not specific for MS and develop as follows: an individual who formerly was very energetic and productive begins to suffer for no obvious reason from periodic fatigue, difficulty sleeping, and nervousness.

Gradually this becomes accompanied by a general loss of strength and endurance, and occasionally by Depression.

The fatigue is precipitated by physical and even mental efforts, and finally becomes continuous. It can only be partially relieved by prolonged rest, much of it in bed.

Many then notice sensitivity to the heat and the burn of the sun, to marked changes in ambient temperature, to hot baths, to fevers from intercurrent infections, and to both physical and psychological stress.

Muscle aching and cramping, joint pains and diffuse slight weakness of the extremeties often develop during long walks, or after standing for long periods, in patients who formerly were energetic and athletic.

These symptoms are usually most severe in cold or damp weather and are relieved as the weather moderates. The usual laboratory tests and X rays for arthritis are negative, yet the patients are considered to have, and many are treated for arthritis.

Peculiar visual symptoms described by the patients as unclear or blurred viaion, and periodic foggy vision, also occur in patients with normal full visual fields and normal visual acuity.

Sensory complaints that the patient describes as "peculiar feelings" lack objectivity and are not taken seriously by the examiner. Finally, some patients complain of deteriorating memory, cloudy mentation, and occasionally of confusion.

All of these symptoms are usually periodic at first; only later do they become continuous. They are brought on by physical or psychological stress, hot weather, hot baths, exposure to sun, and intercurrent infections both with and without fever.

They are not specific for MS since they may occur in other diseases, for example: Hypoglycemia, HypoThroidism, HyperVentilation, and Middle Ear Disease.

Cold, pale hands and feet, periodic subcutaneous Hemorrhages without obviious cause, and often a pale drawn face during the periods of fatigue completes the picture.

p32

These prodromal symptoms have come to light in the last ten years as we have interrogated and examined increasing numbers of patients in early phases of the disease. These symptoms do not lead to a diagnosis of MS and are often confusing.

They finally merge with the definite Neurological Symptoms, in the early phases of the disease. It is of interest that in this stage of the disease the red-cell mobility test often confirms the possible presence of MS.


Early Phase Symptoms

Fatigue is still the most persistent symptom. It may continue to be periodic. Following physical or psychological stress.

It often becomes so severe that the patient is unable to do more than rest: the patient is exhausted. Generalized weakness and varying degrees of instability appear from time to time.

Often Double Vision and Foggy Vision occur, both of which are transient. Lack of mental clarity, memory loss, and slight confusion may soon become obvious to the patient and to the family and friends.

p32

These symptoms usually clear in a few days and are usually missed by the examining physican. Tendon reflexes are apt to be slightly hyperactive, but pathological reflexes will usually be absent.

The patient will describe areas of altered sensations, which the physican will not be able to confirm.

The patient frequently becomes exhausted, has a drawn face, and/or may become increasingly nervous and irritable, unable to work for days, weeks, or months. He or she usually recovers slowly, but on occasion will suddenly feel much better and soon return to normal activities.

Objective findings of significance began to appear, but they may not satisfy the criteria for diagnosis of Multiple Sclerosis.

These symptoms are usually sufficiently severe to alarm the family and friends of the patient. The patient feels relieved that his/her complaints of several years' duration are finally taken seriously.

The family physican is also alarmed and again refers the patient to an internist and finally to a neurologist. Since objective Neurological signs are either absent or not impressive, there is another delay while routine testing is undertaken.

The usual tests of the Spinal Fluid; and the Visual, Auditory, Sensory-Evoked Potentials may still be normal, and the CT scan with enhancement and MRI are also apt to be normal.

Medical people recognize, though, that the patient is ill, and in some cases one or more laboratory tests support this opinion. During this phase the basic character of the disease unfolds.

p33

Exacerbations begin to occur. They can have a sudden onset with full development of a symptom or symptoms in a few minutes or hours; a slower onset during a period of several days before maximum disability is reached, or a gradual development during a period of weeks or months.

The characteristic feature is that the attack, after a variable period of time, recedes (remission occurs), sometimes quickly and seemingly completely; at other times, slowly and incompletely.

Early in the disease, remission tends to be quite complete and often develop soon after the exacerbation or attack. As the disease progresses, remissions fail or nearly fail to occur. For this reason, patients respond well to almost any treatment in the early phase of the disease.

If the diagnosis is made in the early stage of the disease, the patient will probably avoid serious disability, providing he or she follows the low-fat diet carefully and minimizes physical and psychic stress.


Late Symptoms & Signs

The later symptoms are more severe and are accompanied by clearcut objective signs. At this point the diagnosis by clinical means is usually possible, and there is additional support for the diagnosis from the laboratory, which we will discuss in the next chapter.

The following are the major symptoms and objective findings that appear and continue to develop to total disability. The more important visual symptoms are Double Vision and Loss of Vision in one or both Eyes.

The double vision is often accompanied by Nystagmus (rhythmic oscillation of Eyes when gazing off center) or by incoordinant or simply jerky movements of the Eyes.

Visual loss can be confirmed by careful examination of Visual fields or by measuring reduction in Visual acuity. It may be accompanied by paleness of one or both Optic discs.

The important motor symptoms are weakness, and rarely paralysis, of one or more extremities, the face, or trunk. This weakness may, in time, develop into a state of marked stiffness (Spasticity).

The usual sensory symptoms are alteration or loss of sensitivity to pinprick, light touch, position sense, and/or vibration sense.

p34

This usually occurs in the extremities and lower trunk and in the face. Coordination and stability may be impaired, leading to loss of coordination of the extremities and occasionally the trunk.

Other manifestations of this are vertigo, with or without double vision, Nystagmus, nausea, and vomiting.

Added to these symptoms are urgency and frequency with occasional loss of control of the bladder function and less often of the bowels. Impairment of memory and occasional confusion may occur, especially when under stress.

Neurological signs such as hyperactive reflexes, extensor plantar responses, reduced sensitivities, incoordination and Ataxia are common findings upon examination. From this point the disease becomes Progressive with or without occasional relapses.


Multiple Sclerosis Diagnosis

p35

In the early phases of MS, when the diagnostic laboratory procedures are of limited help, the Neurologist must depend almost entirely on the patient's history and examination, and upon his own clinical acumen.

Familiarity with the early symptomatology of the disease is necessary if a correct judgement is to be made at that time. Later the laboratory may add confirmation and even identify lesions in the "silent areas" of the Brain that produce no signs or symptoms.

Clinical Diagnosis

p36

The clinical diagnosis of MS is based upon two main characteristics that are found rarely in other diseases. The first is that the lesions causing the symptoms and signs are multiple and usually are randomly disseminated in the Brain and Spinal Cord.

Consequently, the symptoms and signs are unpredictable and vary a great deal. The lesions are also scattered with respect to time - not all lesions occur at the same time. The second unique feature of MS is that all but a few cases are Exacerbating/Remitting in character.

The exacerbation may develop abruptly, in some instances resembling Stroke. Also, they may develop slowly during several days or weeks, or still more slowly during several months.

After a variable period, which may be as short as one day or as long as several months, the symptoms abate, sometimes rapidly but usually more slowly.

The improvement may be slight, but early in the disease the remissions are usually remarkably complete, so complete that the patient considers that recovery has occurred. Exacerbation/Remission cycles vary with the individual case.

The usual rate is about one cycle per year, but the frequency may be as high as 5 per year and as low as 0.1 per year. In either event, it can be assumed that complete recovery from a cycle is rare: some residue of Neurological lesions are usually retained.

This is indicated by the return of symptoms years after apparent complete recovery, when the patient is exposed to stress: for example, bright sunlight will cause temporary foggy vision and nervousness; physical stress causes weakness, incoordination, reduced vision, and sensory changes, all of which are temporary.

To satisfy these two criteria and arrive at a clinical diagnosis, it is necessary for a minimum of two Exacerbation/Remission cycles or their equivalent to have occured.

Unusual cases occur in which the first exacerbation is accompanied or followed by a CT scan or other diagnostic test indicating the presence of a second lesion in a silent area.

In such cases, the diagnosis is accepted by an increasing number of Neurologist, but not by all. In the prodromal phase of the disease, the symptoms are usually transient and in a sense are Exacerbatin/Remitting.

They may or may not suggest involvement of the CNS and as a consequence, MS is rarely considered and the laboratory tests at that time are of limited help. In the early phase, the patient begins to experience relapses with involvement of the CNS.

p37

By the time the patient is examined by his or her doctor, the symptoms may have cleared up, and the Neurological findings are no longer present or are not convincing.

At this time the doctor has the choice of relying on, or ignoring the patient's history, or dismissing the episode as functional. The diagnostic methods could be of help at this point, but are often overlooked.

Later in the early phase and extending into the late phase of the disease, symptoms begin to be supported by positive Neurological findings, at which time a clinical diagnosis can usually be made.

Support by the laboratory is often available then, but it may not be needed. Our experience indicates that about 97% of cases are Exacerbating/Remitting from the beginning.

As disability developes, the remissions are less complete and eventually do not occur. Then exacerbations no longer occur and the disease becomes progressively disabling. No more than 3% of our cases have been Progressive from onset.

Continued In 17-02



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