Multiple sclerosis (MS) is an autoimmune disease of the central nervous system where the body mounts an immune attack against the myelin sheaths covering nerves. This leads to demyelination and damage to axons of nerves which help to transmit electrical signals that result in progressive neurologic disability.

Digestive issues and gastrointestinal symptoms are common in people with MS and can significantly impact their quality of life. In one survey, nearly two-thirds (65.6%) of patients with MS report at least one persistent gastrointestinal symptom. The most common digestive issues in those with MS are constipation (36.6%), dysphagia (21.1%), and fecal incontinence (15.1%). Functional gastrointestinal disorders like irritable bowel syndrome (IBS) are also very common in this patient population and result in significantly reduced health-related quality of life, increased utilization of health care, and impaired work productivity.

Functional medicine for digestive health in MS offers comprehensive strategies based on understanding the connection between digestive health, and the nervous system, and MS. Functional medicine utilizes specialized testing to guide personalized management plans that can improve gut health and quality of life.

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Understanding the Link Between MS and Digestive Health

The immune and mitochondrial imbalances that contribute to MS result in a range of symptoms, including various digestive problems. An autoimmune attack on the myelin sheath around nerves and impaired energy production due to oxidative stress and mitochondrial dysfunction interrupt the transmission of nerve signals between the central nervous system and the rest of the body. This leads to common symptoms of MS such as fatigue, a loss of control over movement and muscle function, vision problems, balance issues, and an inability to feel various sensations.

MS can therefore impact the gastrointestinal system in various ways that have a significant impact on quality of life. Impairment of nerve signals to muscles along the gastrointestinal tract contributes to digestive problems such as constipation, difficulty swallowing (dysphagia), and fecal incontinence.

Difficulty swallowing can make eating, drinking, and taking oral medications difficult and dangerous. Dysphagia is common in MS, with at least a quarter of patients affected by this debilitating symptom. It can lead to further complications such as malnutrition, dehydration, and aspiration pneumonia if food or liquid enters the airway instead of the esophagus.

Constipation is even more common in people with MS, impacting over half of patients. This condition often develops due to impaired nerve communication with muscles of the gastrointestinal tract combined with inadequate fiber and water intake secondary to dysphagia. The resulting infrequent bowel movements are difficult to pass and contribute to significant bowel pain and bloating.

Impaired communication between the nervous system and muscles of the gastrointestinal tract along with difficulty passing stool can contribute to fecal or bowel incontinence. While not very common in the general population, up to 50% of those with MS experience bowel incontinence at some point with 25% experiencing it on an ongoing basis.

The Role of Gut Microbiota in MS

The trillions of microorganisms that inhabit your digestive tract make up your gut microbiome. While studies are still teasing out which comes first in the loop of brain-gut inflammation seen in MS, we know that the gut and microbiota residing there play a key role in the development of MS.

Multiple sclerosis is caused by a combination of intersecting factors that trigger an autoimmune response in genetically susceptible individuals. Environmental, infectious, lifestyle and nutritional factors impact the gut microbiome and gut health and contribute to the body’s normal immune defenses going awry and attacking the nervous system instead of the normal targets of pathogens or toxins.

Microbes in your gastrointestinal communicate with and influence the brain and nervous system in complex ways via the gut-brain axis. This network facilitates bi-directional interactions that play a key role in the development of neurological diseases like MS.

When the microbes that inhabit your gut become out of balance (dysbiosis), increased inflammation, an impaired intestinal barrier, and dysregulation of the immune system can occur. Your gastrointestinal tract houses gut-associated lymphoid tissue (GALT) that helps to protect the body against harmful microbes and also plays a role in regulating the gut’s normal flora.

When the gut becomes more “leaky” in the setting of dysbiosis, exogenous molecules such as bacterial products and metabolites can get into the bloodstream and trigger inflammation along with local GALT and systemic immune responses. This sets the stage for autoimmunity to develop which can lead to conditions like MS.

Research shows that the gut environment drives the progression of MS. Inflammation in the gastrointestinal tract can develop due to factors like dysbiosis and diet, which can in turn impact both the number and the diversity of microbiota species. This increased inflammation leads to the activation of immune cells (T cells) in the gut that play a role in the initiation of autoimmunity in the central nervous system.

Functional Medicine Lab Testing for Gut Health

Functional medicine laboratory testing for gut health in MS is valuable for uncovering imbalances and distinguishing the root causes of inflammation and immune dysregulation that lead to nervous system damage. Performing a stool analysis, microbiome testing, and assessment of micronutrients can pinpoint areas to address as part of a personalized plan to help slow the progression of the disease, reduce the frequency and severity of relapses, and manage symptoms.

The GI-MAP + Zonulin from Diagnostic Solutions is a comprehensive stool test that provides an analysis of the relative amounts of healthy and unbalanced gut bacteria, inflammation, and leaky gut markers. Together this information can point to dysbiosis and intestinal permeability that may be triggering autoimmunity and perpetuating the cycle of inflammation and damage. This type of testing helps guide a personalized treatment protocol to rebalance the gut microbiome, treat any identified dysbiosis or infections, and address gut dysfunction. Testing can be repeated after several months of treatment to monitor progress and adjust the plan as needed.

Gut health and intestinal permeability are also impacted by food sensitivities. Testing to identify any foods to which an individual is sensitive can be used to guide a personalized nutrition plan designed to reduce inflammation and autoimmunity. The LRA Food Block 96 By ELISA / ACT Biotechnologies measures delayed hypersensitivities to 96 commonly consumed foods to identify foods that should be avoided to reduce inflammation.

When the gut is inflamed and leaky, nutrient deficiencies can occur. Progression and worsening of nerve function can occur in MS when deficiencies in vitamin A, B vitamins, vitamin D3, and omega-3 fatty acids are present. Micronutrient testing from SpectraCell Laboratories can be used to detect any deficiencies that can then be targeted using diet and supplementation.

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Nutritional Strategies for Gut Health in MS

Diet can play a significant role in modulating the gut microflora and thereby altering the progression and outcomes of MS. Nutritional strategies can help people with MS maintain a healthier gut, balance their weight, reduce inflammation, and balance dietary metabolites that impact the immune system and nervous system.

Overall, an individualized anti-inflammatory diet that removes common food allergens like gluten and dairy and any foods to which an individual is sensitive can help reduce inflammation and autoimmunity in patients with MS.

Diet plays an essential role in shaping the balance of gut bacteria. Anti-inflammatory whole foods-focused diets for MS help to improve the composition of the gut microbiome, heal the gut, and modulate immune responses. Eating plenty of plant-based foods like vegetables and legumes provides natural fiber and phytonutrients that support a balanced microbiome, decrease inflammation, and reduce relapses of MS.

Enhancing an anti-inflammatory diet with probiotic-rich fermented foods like miso, kimchi, and sauerkraut can help repopulate the gut with a healthy variety of beneficial bacteria. In addition, prebiotic foods including leeks, artichokes, garlic, and beans help to nourish healthy bacteria. Together, these foods help to nourish a healthy gut, reduce inflammation, and allow for the repair of the intestinal lining to reduce autoimmunity.

Depending on an individual’s needs and testing results, there are specific dietary plans that have been developed to help rebalance the gut and improve symptoms in patients with multiple sclerosis. For example, The Wahls Protocol is a modified Paleo diet that focuses on vegetables, grass-fed meat, and wild fish. This protocol proposes that excluding grains including gluten, dairy, and starches can help to heal the gut by avoiding triggering excess inflammation.

Addressing Common Digestive Symptoms in MS

Managing digestive symptoms in MS requires a personalized holistic approach. Functional strategies for MS-related IBS and other digestive issues like constipation and diarrhea integrate dietary changes, lifestyle modifications, and targeted supplementation.

While a functional medicine approach is tailored to each individual’s needs, some general guidelines often help with common digestive symptoms in MS. For bowel dysfunction like constipation, it can be helpful to drink adequate amounts of water with balanced electrolytes. Many people also find improvement in bowel function when they incorporate fiber from fresh fruits and vegetables, whole grains, and/or supplements like powdered psyllium fiber into the diet. Diet and supplementation should be tailored to your individual needs and testing results under the guidance of a knowledgeable professional.

Maintaining a regular routine and setting aside time for emptying the bowels is sometimes helpful for retraining the bowels with issues like chronic constipation. It is also helpful for bowel regularity to exercise and stay physically active as part of your routine.

Targeted supplementation may also help improve gut function and motility in people with MS. In addition to the nutritional changes mentioned above, herbal remedies and nutritional supplements can help relieve constipation as part of an individualized approach depending on the identified underlying contributing factors.

Magnesium oxide acts as an osmotic laxative to increase the amount of water in the stool and stimulate intestinal contractions to make bowel movements easier. 400-800 mg of magnesium oxide taken before bed can often improve bowel function.

Aloe vera pulp is rich in mucilage to soothe inflammation in the digestive tract and contains anthraquinones which enhance intestinal motility to act as natural laxatives.

The Impact of Lifestyle Factors

Lifestyle factors such as stress, physical activity, and sleep impact the microbiome, digestive health, and MS symptoms. Lifestyle changes for MS and digestion include meaningful stress management, regular physical activity, and adequate restorative sleep.

Stress can contribute to digestive health issues and also trigger and worsen symptoms of MS. Stress hormones like cortisol can directly act on the digestive tract, altering motility and contributing to inflammation. Stress also significantly affects the microbiome and can contribute to increased intestinal permeability, contributing to autoimmunity.

Incorporating mind-body practices like yoga and meditation into your life regularly can help reduce chronic stress. These stress management techniques help to shift the body into a parasympathetic state that can allow for greater healing of the gut and improved digestion. 

Appropriate physical activity is also a great way to manage stress and improve the fatigue and other symptoms that occur in MS. Personalized physical therapy and mindful movements such as yoga and tai chi help people with MS reduce fatigue, increase strength, and improve muscle tone, balance, and coordination.

Balanced exercise not only helps to manage stress and improves symptoms of MS, but it also positively impacts the gut and digestive health. Exercise increases the diversity of the microbiome and can increase the production of short-chain fatty acids (SCFAs) that act as prebiotics to nourish beneficial bacteria.

Restorative sleep is crucial for a healthy microbiome and nervous system and the balance of your gut microbiome can impact your sleep. These microbes influence your circadian rhythm, so when their balance is disrupted (dysbiosis) circadian alignment and sleep can be thrown off. In turn, sleep is very important for neurological health and keeping the microbiome balanced. Make your bedroom a quiet, dark, cool, and comfortable place to sleep for 7-9 hours each night.

Integrative and Complementary Therapies

Since gut health is so impactful in MS, a variety of integrative and complementary therapies have been studied to heal and balance the gastrointestinal tract. Integrative approaches such as acupuncture, meditation, reflexology, massage therapy, yoga, diet, reiki, and Tai Chi can improve fatigue, quality of life, and pain in people with MS.

To support gut health and improve disease outcomes, complementary therapies for MS gut health are imperative. As mentioned above, foods containing prebiotics like bananas, greens, onions, garlic, soybeans, and artichokes and naturally-occurring probiotics like yogurt, kefir, sauerkraut, tempeh, and kimchi can be incorporated into the diet to improve the diversity of the gut microbiome and support beneficial gut microbiota.

Probiotics can also be taken as supplements. One study showed that supplementing with the probiotic yeast Saccharomyces boulardii resulted in a significant decrease in inflammation and improvements in pain, fatigue, and overall quality of life in patients with MS.

Supplementation with the SCFA propionate has also been studied in people with MS. Propionate helps to regulate the immune system. Supplementation with 1 gram of propionate daily helped to restore low levels, reduced the annual relapse rate, and slowed disease progression in people with MS.

Another emerging strategy for modulating the microbiome is fecal microbiota transplantation (FMT). In this approach, feces is taken from healthy donors without a personal or family history of autoimmune diseases and implanted into a patient with MS. Studies show lower intestinal permeability, a more anti-inflammatory state, and enhanced composition of the gut microbiota in patients with MS who have received a FMT.

Antioxidants consumed via the diet and/or supplementation can also help to regulate the immune system, decrease inflammation, and mitigate oxidative stress, preventing demyelination and damage to the nervous system in MS. These include vitamin D, vitamin A, curcumin, and omega-3 fatty acids.

In particular, ‍vitamin D has been extensively studied for its role in regulating the immune system. Lower levels of vitamin D are associated with a greater risk of multiple sclerosis and supplementation of this nutrient reduces relapses and nervous system damage.‍

Studies also demonstrate that increasing consumption of foods rich in omega-3s such as fish, nuts, and seeds and/or supplementation with these fatty acids can improve quality of life and help heal the gut in patients with relapsing-remitting MS as well as helping to ameliorate neurodegeneration. A systematic review found that omega-3 and fish oil supplements benefit patients with MS by reducing relapse rates, decreasing inflammatory markers, and improving quality of life.

Challenges in Managing Digestive Health in MS

MS is a complex condition with a wide range of symptoms that impact the whole body and quality of life. The accompanying fatigue, pain, mobility problems, and digestive symptoms take a toll on the body and mind.

A multidisciplinary patient-centered approach to care is needed to address the challenges in managing digestive health in MS patients and the overall complexity of the disease. Tailoring a personalized management plan to an individual’s needs, testing, preferences, and symptoms can help bring greater balance.

A functional medicine approach to digestive health in MS patients looks at the contributing underlying factors that are leading to symptoms. Environmental factors, dysbiosis, immune system dysregulation, and intestinal permeability all contribute to gut health imbalances in MS via the gut-brain axis.

Medications used to treat MS can impact the microbiome. Some may contribute to dysbiosis while others can have a favorable impact. For example, dimethyl fumarate (DMF) is an oral medication used to treat relapsing-remitting MS. It has anti-inflammatory and neuroprotective antioxidant effects and impacts the gut–brain axis by increasing beneficial bacteria that produce SCFAs, reducing the permeability of the intestinal barrier, and having an antimicrobial effect.

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Digestive Health in Patients with Multiple Sclerosis: Key Takeaways

Gastrointestinal symptoms are extremely common among people with multiple sclerosis and the health of the gut plays a key role in the development of immune dysregulation and inflammation underlying this autoimmune disease.

Gut health and the balance of microbes inhabiting the intestinal tract have significant impacts on the immune system and nervous systems via bi-directional communication along the gut-brain axis. Dysbiosis of the gut microbiome is associated with immune dysregulation and progression of MS.

Therefore, a comprehensive individualized approach to digestive wellness is needed to address the unique needs of MS patients. Functional medicine provides a holistic approach to digestive health in MS using specialized testing to assess the health of the gut. A personalized management plan utilizing lifestyle, diet, supplements, and integrative approaches can then be put into place to help rebalance the gut, calm inflammation, and improve quality of life.