Calling all vegans

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As a vegan what supplements do I need to take?

I am in the process of researching the dietary landscape for people with MS and will not be ready to make any firm recommendations for some time, but I can make a recommendation of what diets to avoid. The first is a strict vegan diet without supplements.

My index patient was an Asian woman, in her mid-20s, with RRMS who referred for a second opinion about worsening MS symptoms and escalation therapy. She was on glatiramer acetate and was complaining of progressive visual disturbance and painful pins and needles in her hands and feet. When I saw her there was little doubt she had RRMS, but it was clear to me she had superimposed vitamin B12 deficiency as well. She had bilateral visual failure (6/60 vision) with large central blind spots and when I looked into the back of her eyes her optic nerve was very pale indicating she had lost a lot of nerve fibres in the eyes (optic atrophy). The clue to the diagnosis was that she was pale and had a smooth red tongue (atrophic glossitis) and she had lost sensation in her feet and her tendon reflexes were depressed (neuropathy). Other problems included excessive fatigue, shortness of breath with minimal exertion, memory loss, poor concentration and attention, irregular periods and patchy hair loss. When I asked her about her diet she volunteered to be a vegetarian for most of her life and had become a strict vegan in the last 5 years.  Apart from the intermittent use of iron supplements for anaemia, she was not taking any supplements. When I checked her blood results she had very low vB12 levels and mild anaemia with a mixed pattern due to a combination of being iron and vB12 deficient. Tragically this patient’s visual function did not recover on vB12 supplements and her peripheral neuropathy became very painful presumably as the nerve fibres started to recover in her feet they started to fire aberrantly causing pain. She is now registered legally blind; a tragedy as her visual loss was preventable.

In addition, to this patient in my 5-years of doing the physician’s clinic at Moorfields eye hospital under Professor W. Ian McDonald’s mentorship, I must have diagnosed subacute combined degeneration of the spinal cord due to dietary vB12 deficiency in at least 5 other patients who were vegans. I have also seen a remarkable case of a lady, who was a vegan, who presented with pins and needles around the mouth and a numb tongue. She was not vB12 deficient as she was taking vB12 supplements, but when I did her peripheral metabolic profile she was profoundly zinc deficient and also had low levels of selenium. Within a week of going onto zinc and selenium supplements, her symptoms resolved.

From an evolutionary medicine, perspective veganism is not natural. We evolved as omnivores, i.e. vegetable and meat eaters; our metabolism tells us this and hence a strict vegan diet is unnatural and unbalanced. If you are vegan you need to make sure you supplement your diet with the following essential nutrients and minerals:

  1. Vitamin B12
  2. Iron
  3. Zinc
  4. Iodine
  5. Calcium
  6. Essential fatty acids, in particular, omega-3 fatty acids

The following may need supplementing:

  1. Vitamin D (you can get sufficient from sunlight exposure at the correct time of the year). At Barts-MS we recommend that all our patients and first- and second-degree relatives take vD supplements according to the vD Council’s recommendations.
  2. Selenium (you can get sufficient selenium from some vegan food sources, e.g. brazil nuts, mushrooms, sunflower seeds and beans)
  3. Protein (adults can get enough protein from a vegan diet, but children and people in a catabolic state, for example with certain diseases, may need additional protein sources)

If you have children on a vegan diet you should be careful about making sure they get enough protein and the above supplements. If not they may become stunted.

The bottom line; strict veganism is not natural in health and/or disease and is deficient in several key nutrients and minerals that need to be supplemented. This is a problem for people who are on the breadline; supplements are relatively expensive and hence vegan diets put poorer people at greater risk of the health consequences of an inadequate diet.

Please note that vB12 is essential for myelin metabolism and is the reason why when you are vB12 deficient you get a mixed demyelinating and axonal nerve loss picture in the optic nerves, spinal cord and peripheral nerves. There is a body of literature showing that pwMS tend to have low vB12 levels and this may be an indication of them needing more vB12 that the average person as it is consumed as part of myelin turnover. I therefore suspect that pwMS are even more senstive to vegan diets than people without MS.

Baroni et al. Vegan Nutrition for Mothers and Children: Practical Tools for Healthcare Providers. Nutrients. 2019 Jan; 11(1): 5.

As the number of subjects choosing vegan diets increases, healthcare providers must be prepared to give the best advice to vegan patients during all stages of life. A completely plant-based diet is suitable during pregnancy, lactation, infancy, and childhood, provided that it is well-planned. Balanced vegan diets meet energy requirements on a wide variety of plant foods and pay attention to some nutrients that may be critical, such as protein, fibre, omega-3 fatty acids, iron, zinc, iodine, calcium, vitamin D, and vitamin B12. This paper contains recommendations made by a panel of experts from the Scientific Society for Vegetarian Nutrition (SSNV) after examining the available literature concerning vegan diets during pregnancy, breastfeeding, infancy, and childhood. All healthcare professionals should follow an approach based on the available evidence in regard to the issue of vegan diets, as failing to do so may compromise the nutritional status of vegan patients in these delicate periods of life.

About the author

Gavin

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

48 comments

  • So much hype around veganism, even though it’s clearly unhealthy and potentially dangerous given that a person may become defficient in so many essential nutrients. As profG wrote, it is an unnatural diet.
    It shows how detached we are from our roots. Humans evolved in the nature and they ate not only animals but also their products. I understand that there is a moral issue with meat eating, hence there is a good reason to be a vegetarian. But being a vegan? This is an urban trend of our times.

    • Sorry, my previous comment suggested that I thought my lack of meat/supplements/eating not so well was causing my symptoms to get worse,that’s not what I meant,duh brain…… I meant to say that the article made me think how my diet should be wide,varied and healthy just to keep me feeling that I was trying to keep my body as healthy as poss

  • Where do you stand on the plant-based plus fish diet recommended by the OMS charity? You have an endorsement in the OMS book for its approach to the disease but, other than fish, it advocates a completely vegan diet. Is fish enough to overcome the issues you outline?

    • ‘other than fish, it advocates a completely vegan diet’. This is incorrect. Read the book again or jump on the OMS website for clarification.

    • The OMS diet is the one thing I have never supported. There is no evidence to suggest it is better than any other diet. Unfortunately, when it comes to diet and MS the evidence is paper thin. However, from a general health perspective diet is important and there are some general principles that need to be followed. The OMS diet does address some of these principles, but to say it is better than any other diet is wrong and to say it improves MS outcomes is also wrong.

      The problem with ‘fad’ diets is that they are often non-compliant with the cultural values of your family, extended family and nationality. Food is more than food; it identifies you and your culture and plays a very important social function. It is important not to say to someone in Scotland that haggis is bad for you and you should only eat a Mediterranean diet. You have to realise that eating haggis is an important Scottish tradition. Stopping Scottish MSers eating haggis and celebrating with haggis would be challenging their national identity.

      • “You have to realise that eating haggis is an important Scottish tradition. Stopping Scottish MSers eating haggis and celebrating with haggis would be challenging their national identity.”

        That’s _total nonsense_. I’m Scottish. I can quote Robert Burns and eat the excellent vegetarian haggis instead.

        Haggis is such a stereotype. E.g. tatties and herring are arguably more Scottish.

        https://youtu.be/pYfkk8bSuyM

        • But you have just proved the point you still eat haggis; fortunately, you have a vegetarian option. I would be interested to know what the average Scot thinks of the vegetarian option? For obvious reasons, I am a big fan of biltong. South Africans were up in arms when someone tried to brand dried mushrooms and aubergine as vegetarian biltong. By definition, biltong is dried meat.

          • No. I don’t have to eat the traditional haggis to be Scottish. _That_ is my point.

            I also hate tartan and whisky. But I know a lot about Scottish music and wildlife. I can speak in a genuine Scottish dialect, but I am as proud that I can speak fluent German as well.

          • The point I am making is that food often defines who people are and to tell them should stop eating xxx because it is unhealthy has unintended consequences. This is important because in inner-city America sociologists have discovered that some types of so called junk-food now define certain cultures and around it, a new language is emerging; a street lingo. To reverse this phenomenon is going to take a lot more than telling these people to stop eating junk food because it is unhealthy; stopping them eating junk food challenges their identity.

      • But your name is on the stuff that came with the OMS book they sent me free. I’ve just read the leaflet again and it says the BOOK is what you “would have no hesitation in recommending to my patients and also my friends and colleagues”. I presumed after reading that you were saying the OMS DIET was ok because it is SUCH an intrinsicall part of the book?
        My hopes are pretty much pinned on that diet and taking Copaxone.

  • I don’t like labels, but tend towards “non strict vegan”, mainly because I am intolerant to dairy and egg protein. Beef and chicken upset me too. I do eat fish occasionally and supplement B12. I’m not anaemic, my doctor said my iron levels were good for a menstruating woman, and I’m an ideal weight with good musculature. My dairy substitutes are fortified with calcium etc. Nuts and seeds are good sources of some nutrients you mention, e.g. walnuts are good for omega-3, pumpkin seeds for zinc.

    Eating meat made me more prone to constipation, an unpredictable bowel and feeling tired. Diet must suit the individual and needs care and thought, not strict rules, either for or against meat.

  • Thank you for putting this information out today.i have Rrms.and over the last year have become “semi vegetarian”, I feel that my ms have got worse,I’m not saying I think it’s because of the lack of meat but the fact that I probably am lacking in certain food sources. It’s good that you have flagged this very important I formation up today as it will make me reconsider my diet,……I do love a good burger.

  • I think it’s great that you’re researching the topic of diet in MS. It will spare a lot of PwMS the bother of endless researching and interpretation of all the info around. Two years ago I did the 8-week blood sugar diet, lost weight (intentionally) and have kept it off by following a low-carb regime. Basically, I eat potatoes, pasta and bread only as occasional treats and use veg substitutes – e.g. spiralised courgettes, cauliflower rice, roast squash together as many veg sides as I can fancy. I aim for high protein by eating full-fat Greek yoghurt, white meat, eggs and fish but don’t exclude red meat. I try hard to avoid processed food and added sugar. Now I’m retired I have the time to cook from scratch – IMO if you can’t or won’t commit to spending time in the kitchen, a healthy diet is very hard to achieve.

    • Kay I think you have hit the nail on the head.

      My take on diet is to eat ‘real food’, prepare it yourself and avoid processed food as much as possible; in particular, processed carbohydrates. I exclude fermented foods from the category of processed foods; we have been eating fermented foods for millennia and this has allowed our metabolism to adapt. I suspect naturally fermented foods are good for us. Another rule is don’t ignore your nationality and culture when cooking and eating.

      • ‘Gut’ by Gulia Enders is a very amusing and interesting book on the gut (not surprsingly) and makes a strong case for fermented foods as well as a correlation between what we put in our guts and our brain health. It would be interesting if your study of diets made links with this take on brain health.

      • Re: fermented foods, can I recommend the Clever Guts Recipe Book, written by Michael Mosley’s GP wife and showing how to analyse/improve gut health through diet and the role of pro-and prebiotics. It also explains the negatives of processed foods. Very good recipes, although I draw the line at seaweed…!

          • Seaweed is an interesting case of how we are not just our genomes, but a metagenome. For example, we need to be colonised with Bacteroides plebeius to be able to digest Nori seaweed. All Japanese are colonised with this bacteria that allows them to eat, digest and absorb the nutrients from seaweed; not us Westerners. However, I wouldn’t be surprised if you could buy a probiotic containing these seaweed loving bacteria to convert our intestines into a seaweed digesting organ.

  • I’m vegetarian, some days vegan but never eat meat.

    There was an article on the BBC radio 4 recently about an NHS cardiologist who’s mother was vegetarian, and the mother passed way aged 68.

    The cardiologist suspected a lack of protein in the diet and knew her diet was poor, as her diet was full of highly processed and junk food including cakes and biscuits, may be to keep up her energy levels. The poor diet is suspected to have led to increased infection vulnerability.

    I know it’s easy to fall in the cakes and sugary snacks routine when busy out and about.

    • I think it is important to note that there is some evidence that suggests that zinc may be involved in the pathogenesis of MS: https://www.ncbi.nlm.nih.gov/m/pubmed/27282383/ Given the uncertainty here, I would think that it would be prudent for persons with MS to be very cautious in employing zinc supplements. Indeed, this is what neurologist Alan Bowling counsels in his book Optimal Health with Multiple Sclerosis (which reviews the efficacy (and lack thereof) for most supplements and diets commonly employed by MSers).

      • Only a small intake of zinc is necessary. Currently, the recommended dietary allowance (RDA) for zinc in the United States is 8 milligrams (mg) a day for women and 11 mg a day for men. Vegans don’t get this amount from their diets.

      • I find it rather worrying someone in your position and with your influence recommends Harcombe and Tiecholz. These people are not scientists or dieticians. They are cherry picking data to fit their beliefs to sell books. Which is fair enough but much of their work has been discredited by actual real dieticians. Follow the science please Prof. I recommmend @kevinnbass

        • And Gary Taubes? He deserves a Nobel prize for his ‘Good Calories Bad Calories’ masterpiece. It was Taubes who uncovered the influence of the food industry on dietary guidelines.

        • Harcombe has a PhD and her meta-analyses are widely regarded. She is not some loony and has a lot of success with her dietary approach.

          • I am not suggesting for a second she is some ‘loony’. But she is not the ideal person to be advising the general public on diet and nutrition. A PhD based on an economics degree with very little nutrition research. Why is she suggesting people don’t take statins? This is worrying stuff. There are numerous real dieticians out there who we should be listening to rather than the latest fad diet authors. I agree Unwin is a far better resource.

  • Re ‘My index patient was an Asian woman, in her mid-20s….’

    I hope this is an illustration not a real person as that is a tragic case of neurological symptoms being wrongly put down to MS.

    Great thought-provoking post, always so worth thinking in evolutionary terms.

    We certainly didn’t evolve to eat processed foods, trans fats, hydrogenated fats, veg laced with glyphosphate, or meat and dairy from animals and birds crammed into confinement so tight they’re fed routine antibiotics to survive and stuffed with growth promoters.

    On the other hand, we have evolved to eat plants, fish, meat and dairy (including saturated fats). Whatever it says in OMS!

    Sorry, that came out a bit of a rant 😉

    So far as protein goes, meat and fish are expensive, eat less. Beans and pulses are cheap, eat more. I think the word is common sense or #flexitarian

    • Re: “I hope this is an illustration, not a real person as that is a tragic case of neurological symptoms being wrongly put down to MS.”

      Tragically this is a real case. The details have been changed to ensure the case has been anonymised.

  • Isn’t it inaccurate to use veganism ? veganism doesn’t correctly reflect the reason why the majority of people with MS change their diets. Its not about veganism.

    vegan : a person who does not eat or use animal products.

    I do not eat meat or diary – i have plenty of fish and healthy diet. Even if i decided to stop eating fish; i won’t be a vegan. i will be someone who doesn’t eat meat, fish or diary… the definition above will explain the difference.

    I am pretty sure its documented somewhere that you advise to have a low calcium intake and NOT to supplement when following a high level of vitamin D – so why would this be different to someone who is a “vegan” diet?

    There are negatives to eating red meat that are well documented and shouldn’t be ignored. Y

    I take b12 as I understand its very hard to get from diet – vegan or not…

    I think you should be careful not to cross the line with your opinion on your blog and twitter. You should not lightly say stuff as your words reach a HUGE number of people and surely you have responsibility to follow your own stance. of running trials and facts. And not hunch or opinion. its not fact that because my family eat a certain way i should.

    • vegan: a person who does not eat or use animal products.

      Yes, that is correct this post is about vegans, people who don’t eat animal products.

    • Re: “I am pretty sure its documented somewhere that you advise to have a low calcium intake and NOT to supplement when following a high level of vitamin D – so why would this be different to someone who is a “vegan” diet?”

      A vegan diet is very low in calcium and they are putting themselves at risk of developing osteopenia and osteoporosis. vD and calcium supplements are recommended for vegans.

    • Re: “There are negatives to eating red meat that are well documented and shouldn’t be ignored.”

      The negatives are based on association studies with many confounders. I am not aware of one study showing a causal link between red meat consumption and ill health. In fact, some of the healthiest populations on the planet are big red meat eaters. You should read Nina Teicholz’s and Zoe Harcombe’s analyses of evidence against red meat; it is much weaker than we are led to believe. The main reason for reducing red meat consumption is environmental (global warming) and not health.

    • Re: “I think you should be careful not to cross the line with your opinion on your blog and twitter.”

      Interested to know what line I have crossed. It is standard practice for vegans to have to take supplements and be advised to take supplements. I think you have misinterpreted who this blog post is for. You seem to think it has been written for vegetarians and/or pescatarians, i.e. non-meat eaters when it has been written for vegans with MS. It is entitled ‘Calling all Vegans’ for a specific reason and is not for people like you who seem to be eating a balanced diet.

  • One shouldn’t forget that it is also possible to be an omnivore and eat very unhealthily, go short on a lot of nutrients, have too much sugar and fat, not enough fibre.

  • I have been vegan for 24 years (for ethical reasons, not for health). I am now 41. I was diagnosed with MS in October 2018 following RIS diagnosis the previous year, due to the number of lesions in my brain and cervical spine (MRI for unrelated issue), and as new lesions have appeared since then. Except for some numbness, I haven’t experienced any neurological symptoms. I am generally healthy and eat a varied diet. I work full time in a demanding job. I currently supplement with Vitamin D, magnesium, flaxseed oil and a multivitamin (includes B12, zinc etc). Before the RIS diagnosis, I only supplemented with a multivitamin. My levels have always been good – the only exception was low vitamin D revealed after the RIS diagnosis.

  • We evolved as omnivores, i.e. vegetable and meat eaters; our metabolism tells us this

    I don’t think evolutionary arguments are useful at all. We have evolved just eating whatever, to stay alive. And often starving to death, suffering malnutrition or being poisoned. A well informed vegan diet is very healthy. Diet is ideally an individual, considered thing. An “omnivore” who eats meat can still miss out on many things in their diet, e.g. fibre.

By Gavin

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