Episode 466: Everything You Ought to Know About Diet and MS with Dr. Tyler Titcomb

0:18 It's August 4th, and we have a lot to talk about. I get more listener email about diet and MS than almost any other topic. So this week, we're taking a deep dive into that subject with Dr. Tyler Titcomb. Dr. Titcombe is an assistant professor in the Department of Dietetics and Nutrition and a registered dietitian with a Ph.D. in Nutritional Sciences in the Department of Neurology at the University of Kansas Medical Center. In a moment, we'll meet my guest, Dr. Tyler Titcombe. When you're living with MS, a healthy diet can play an important role in managing energy levels, supporting immune health, and helping you feel your best.

1:03 Dr. Tyler Titcombe is an assistant professor in the Department of Dietetics and Nutrition and a registered dietitian in the Department of Neurology at the University of Kansas Medical Center. Welcome to the podcast, Dr. Titcombe. Thanks for having me, Jon. Your training is as a registered dietitian with a PhD in nutritional sciences. And you've noted in the past that while we clearly understand the nutritional implications for diseases like diabetes or celiac, neurodegenerative diseases have historically been a black box. What drew you to focus your career specifically on this research gap? You know, I have a long-winded answer for that. I'll try to keep this short.

1:47 If you're familiar with Camp Lejeune, which is the marine base in north carolina that had the contaminated water wells for about 35 years yes um i'm the first, person in my family in four generations who did not live on that base, so i have witnessed you know people i care about develop these terrible conditions you know by the age of 50. And really, I got into nutrition because I was a young kid and I was thinking very narcissistically and I wanted to try to prevent that from happening to me. You know, I didn't understand what the cause was then, but I knew that there was this thing happening in my family.

2:29 And I went to college, and I had mind expansion, and my worldview grew, and I realized that while preventing that from happening to me is one thing, it would be really meaningful to me to help understand how we can prevent this from happening to other people. And my family was afflicted by alzheimer's disease parkinson's brain cancer bladder cancer you name it, but ms was not one of the conditions that affected my family and i did not want to have the like very intimate emotional tie with what my research focused on, um so i actually wanted to originally study MS during my PhD, but unfortunately the individual I had planned on working with in between the time I was accepted and actually got to Madison, Wisconsin for my PhD, her husband had a major health event and she decided that she was not going to take another student and retire.

3:35 So I had to deviate, study something else for my PhD, but then when I was looking for a postdoc, I reminded myself of why I originally set out to do this, and it was to study, a complex disease that doesn't currently have a really good foundation of understanding nutritionally. That's what led me back to MS. So let's get to the question that most people with MS wonder about, and if you read the social media posts, some people with MS claim to have already found. Is there such a thing as an MS diet? I would say right now, no. I am open to the idea that there may be one in the future.

4:17 The field of studying nutrition in MS is relatively new. If you go and you download all the articles that have ever been published on PumMed looking at diet and MS, You'll see that from, you know, the first article in 1948 until about 2014, there was almost nothing, you know, one to two articles per year, maybe. And then 2014 comes along and all of a sudden it goes exponential. Now we're getting hundreds of publications per year in this field. So we just we really don't understand how nutrition and diet you know interacts with the immune system and interacts with a dysregulated immune system for that matter in the context of ms, One day, hopefully, we get there. But today, right now, my answer is no.

5:14 Your research has analyzed the data from the WAVES trial, which looked at two diets that are fairly well known to the MS community, the swank low-saturated fat diet and the Wahls-modified paleolithic elimination diet. For a lay audience, how would you briefly describe the fundamental differences between these two approaches? Do you mind if I start with the similarities absolutely feel free okay so starting with the similarities of these diets they both recommend reducing intake of ultra-processed foods, and they both promote the intake of fruits and vegetables, now where they differ is on basically which component of the diet these two diets pinpoint as the problematic component for MS.

6:08 The swank diet is under the assumption that saturated fat intake is problematic for MS. The swank diet aligns really well with a Mediterranean diet, and it actually adheres really well to the American Heart Association dietary guidelines for cardiovascular disease. The Wall's elimination diet has a different And actually multiple food components that it is pinpointing as the problems. It assumes things that we're going to refer to as dietary antigens Are problematic for MS Dietary antigens are things like gluten from gluten-containing grains Casein from dairy, And lectins from nightshades, And the idea is that these antigens, when we consume them, they cause inflammation in the body.

7:02 And by removing them, you can reduce your inflammation and have a favorable health impact. Your secondary analyses showed that both diets led to reductions in fatigue and improvements in quality of life. From a nutritional standpoint, what do you think is a common denominator here? Is it what these diets are adding like micronutrients or what they're eliminating like ultra processed foods or perhaps all of the above or none of the above? Yeah, you know, that's that's a great question. And and ultimately, we always want to be able to point a finger at like one thing. Right. And unfortunately, when we're talking about nutrition, any any time you eat something, you're consuming hundreds, if not thousands of different chemicals.

7:50 And these chemicals, as they go through your body, they interact with every single system, every single pathway, and every single cell that's in your body, whether it be directly or indirectly. Nutrition is actually your second largest daily exposure after the air you breathe, so you know i to answer your question i think it's the combination of reducing uh, the things that we know are harmful from a diet and ultra processed foods that are rich in add sugar saturated fat and sodium, and then on the flip side increasing intake of foods that we know have beneficial compounds, fiber, phytochemicals, micronutrients, things like this.

8:39 But yeah, I know, again, I'm giving you like a very, you know, vague, nonspecific answer, but that's where we are. One of your papers noted that diet-induced improvements in functional disability are heavily mediated by changes in fatigue. Can you unpack that in plain English for someone who's living with MS-related fatigue? Yeah, so we've shown time and time again that dietary interventions are associated with reduced fatigue and MS. That's probably the one thing that we have the best evidence on.

9:22 And that secondary analysis you just mentioned, we were attempting to look at how, or whether, I should say, dietary interventions can impact something more objective, like disability. And to do this, we use the MS Functional Composite, which is a composite metric that includes the time 25-foot block, the nine-hole peg test, and the symbol digit modalities test. And we did show that those values, the MS Functional Composite values, reduced over time, which means a reduction in functional disability. But because we know that fatigue reduces, and we know that fatigue is associated with disability, we want to investigate, was this relationship actually due to these reductions in fatigue?

10:13 And that's essentially what we showed. We showed that this reproducible effect that we know to be true, that diets reduce fatigue, that reduction in fatigue is actually what was associated with the reduction in functional disability. So, you know, to kind of unpack that, we did not show that these diets impact MS disability accumulation. But what we did show is that they may be indirectly impacting at least the subjective experience of disability. You know, reducing fatigue maybe makes people more able to do things, and therefore they experience reductions in disability as far as we measured them.

10:59 I've heard that one of the most challenging aspects of conducting a clinical trial that's focused on diet is that, as many of us well know, staying on a diet is hard. Now, during the pandemic, I think you analyzed interviews with clinical trial participants and their support partners to look at the barriers and facilitators to sticking to a diet. What are the biggest real-world hurdles people face when trying to change up their eating habits after a diagnosis? You know, one of the things that I see in my faculty practice clinic regularly is.

11:40 Is that a lack of support is really detrimental to changing behavior. So, you know, I've had some patients where they personally are really motivated, to change their diets and try to be healthier. And I will have conversations with them about, you know, how supportive of this is your home environment? Like, you know, do you have children you have to be cooking for? Or do you have a supportive spouse? You know, things like this. And the biggest barrier that I encounter, and even in that paper you mentioned, this was one of the top barriers, was a lack of support from the home environment.

12:21 So in order to facilitate, you know, healthy dietary changes. If my patient who's, you know, in my exam room with me, if their spouse is with them, I will talk to their spouse about what their spouse needs to be doing as well to help support the person who's living with MS and changing their diet. I also recommend things like finding online support communities, things like this. And then, you know, I'm a dietitian, so I'm biased, but I think one of the best ways to get support for changing your diet is to see a dietitian. You know, the caveat to that, though, is that, you know, I'm one of, as far as I know, about 12 MS dietitians in the country, so we're few and far between and hard to find.

13:06 But any dietitian should be able to help a person living with MS improve their diet. In your recent, I think, March 2026 secondary analysis, you explored how baseline lifestyle factors like physical activity, sleep, and alcohol consumption modify the effectiveness of a diet. In that process, what did you discover about who benefits the most from a dietary intervention? So this is a secondary analysis. So we have to, you know, have a level of skepticism when we look at these results, because they need to be replicated. But this is something I'm actually pretty excited about. One of the key groups of individuals who benefited the most from the dietary interventions that we did were individuals who had low physical activity at baseline.

13:57 People who had high physical activity had less benefit as far as the outcomes we were looking at. So what this suggests to me is that people who are physically active, we know that they're doing one healthy lifestyle behavior, they may be doing others. So they maybe have less room for improvement. But where this is exciting to me is, you know, in MS, there's a certain percentage of people who are unable to do physical activity. And these are the exact people that that secondary analysis said may benefit the most from changing their diets.

14:37 And you can look in weight loss literature, too, and see the same exact thing. You know not MS specific of course but the other group from that study who had larger benefits were people who consumed lower levels of alcohol, so if we take the same analogy from the physical activity is saying that people who had low physical activity have more room for improvement you might assume that people who consume high amounts of alcohol may have more room for improvement as well. But we actually saw the reverse. And what this may suggest, again, requires more exploration on this, but potentially the detrimental effects of high alcohol consumption outweigh the beneficial effects of a dietary intervention.

15:27 Something that needs to be worked out further, but I think the fact that, you know, identifying that people who consume low amounts of alcohol and do low physical activity benefit the most from dietary interventions means that we can actually, you know, in the clinic, potentially identify those who would benefit the most from a referral to a dietician, for example. People often associate malnutrition with being underweight, but you've actively reviewed screening methods for malnutrition in chronic disease populations. So what should patients and clinicians be looking out for to ensure that a restrictive or therapeutic diet isn't accidentally causing harm?

16:10 Yeah, so this is something that I'm very keenly looking at. Interested in. So when we hear the term malnutrition, like you said, we tend to just automatically think about a person who's in a small stature body. The problem with that is that malnutrition can occur across the spectrum of BMI. So whether someone lives in a smaller body or someone lives in a larger body, risk of malnutrition, you know, is the same. So when a person has a reduction in appetite due to one reason or another, and they're losing weight without trying to, those are the two key considerations when we're talking about protein, energy, malnutrition in the context of chronic disease.

16:59 And obviously this is biased, but I would say that, you know, somewhere around 70 to 80 percent of the referrals to my faculty practice clinic are for these individuals, so you know when we're talking about you know especially some of these ms diets that are very restrictive and they eliminate complete food groups, in doing so uh you know we're we're removing potentially a source of key nutrients, um there also sometimes is this this thing occurs where a person will.

17:40 Develop what's called orthorexia orthorexia is essentially the fear of consuming something wrong because it will cause a symptom, and when orthorexia takes hold. Um you know people will start socially isolating they won't go out to restaurants they won't go to family gatherings because they might eat the wrong food or they might eat a food that's contaminated with something, And that situation alone is a big risk factor for malnutrition, social isolation. So, you know, in my practice, I don't recommend super restricted diets.

18:22 I actually encourage people to eat things that make them happy, but we're going to put some framework around it, some guidelines about, you know, the quantity, the portion size, and how frequently we're doing this. So, you know, a clinician, if you have a patient who's, you know, discussing that if they eat, pick a dietary component, and it causes some sort of symptom, so they completely avoid it, that might be an individual who would benefit from a referral to a dietician to kind of unpack that a little bit. You've published work highlighting that despite the massive role that diet plays in quality of life, registered dietitians are rarely integrated into the standard multidisciplinary care team for a neurological condition.

19:14 Why do you think that gap exists, and how do we close it? You know, I've put a lot of thought into this, and I don't have a real straight answer, but I have a couple suspicions. So in MS specifically, you know, MS occurs at an earlier age than a lot of these other conditions do. And in adults, you know, in the absence of food allergy or, you know, very specific cardiometabolic conditions that necessitate a dietician to be on the care team, we tend to assume that until a person becomes an older adult, they don't have nutritional risk.

19:57 You know, maybe some outside extenuating circumstances like, you know, poverty, famine, etc. Can cause that. But just generally, we don't assume that people in their 30s are at nutritional risk. So I think that in and of itself is one of the reasons. Um another reason i think is that you know. I've mentioned multiple times how you know the the research area of nutrition ms is in its infancy, and because of that there has been um you know an influx of individuals making recommendations that maybe aren't nutritionally sound.

20:44 And I think that that has kind of, for lack of a better word, tainted the view of the role of nutrition, even conventional nutrition done by a dietician in MS. And then just, you know, very practically, what one of the biggest barriers is right now. I mentioned earlier that I know of, you know, 11 other dietitians who are MS dietitians in the United States. We're a very small workforce. And, you know, we do receive training in dietetics school on caring for neurological conditions and MS being one of them. I frequently reference one of my textbooks that actually has a chapter on MS in it.

21:27 That was published in 2010. But there's just, there's, there's some, there's some disconnect on, on, you know, the current MS care team and incorporating a dietician and how do we do it? Uh, will insurance reimburse that care? How do we find the dietician, et cetera? So you know one of the things that i'm working on is trying to close that gap and, um i'm doing a couple things uh regarding that one of which, i'm on a task force uh from the academy of nutrition and dietetics that's putting together an advanced certification training for dieticians in neurodegenerative diseases and this includes ms as one of these conditions.

22:15 I also, you know, in my new job as an assistant professor at KUMC, I'm training future dieticians. So I'm doing everything I can to, you know, bring in MS into the classes I'm teaching and making these students aware that you can care for a person with MS as a dietician. And, you know, it really doesn't change anything about how you practice dietetics other than now we're looking through the lens of MS and the specific barriers and challenges that it may cause. Well, I'm hopeful that this conversation is going to spur lots of conversations in examination rooms, and hopefully that gap slowly begins to close a little bit.

23:01 You know, there's certainly no shortage of information on any subject when you go online, and what you find there is, you know, the good, the bad, and the ugly. If some of our listeners are feeling just completely overwhelmed by the conflicting nutritional advice they find on the internet, whether it's the Reddit threads, the influencers, or even the opposing protocols, what is one evidence-based practical step that they can take in their kitchen today to support their brain health? You know, I think we all kind of intuitively know, to some level what a healthy diet looks like i i'm kind of optimistic so so i may be wrong on that but, so i i think you know really just trying to identify, what are the shortcomings in a person in your own diet and and you know identifying strategies to, to be better in that area so you know if you're a soda drinker attempting to reduce the amount of soda maybe replacing it with like a carbonated water, for example, really good strategy.

24:17 If you're a person who doesn't consume fruits or vegetables, can we identify one fruit or vegetable that you like, and can we start trying to include that? You know, if all you consume is white bread, white rice, white pasta, can we identify one of those and convert it to the whole grain version? So whole wheat bread, brown rice, whole grain pasta, it doesn't have to be a complete overhaul, but just identifying those few things that you as a person tolerate and are happy with and sticking to them is really the best thing that that can be done.

24:58 Dr. Tyler Titcomb, I want to thank you for all you do to help people living with MS better understand that changing their behavior when it comes to diet can help them enjoy a better quality of life. And thanks so much for talking with me today. Yeah, thanks so much for having me. That's going to wrap up this episode of Real Talk MS. Real Talk MS is powered by the National MS Society, and you can share this episode of the podcast by letting your friends or family members know that all they have to do is point their web browser at realtalkms.com slash 466. You'll find that link in today's show notes, so you can easily copy and paste it right into an email or a text.

25:41 From time to time on this podcast, we've discussed the concept of shared decision making, and that's where the topic seems to be anchored, as an important concept, but one that isn't always found in real-world practice. Next week, you'll meet Dr. Eliza Ben-Zachariah and Linda Lackman. Dr. Ben-Zachariah is a Nurse Practitioner specializing in MS care, and Linda, who's been living with MS since 2005, is her patient. We'll learn what shared decision-making looks and feels like when it's working well, and we'll hear about the work it takes on the part of both the health care provider and the patient to make shared decision-making work.

26:23 I hope you're planning to join me for next week's episode of Real Talk MS. I'm Jon Strum. Thanks for listening. Stay safe and make healthy choices.