Food For Thought – Diet, Disease & ALS / MND with Amber Sewell-Green

Voice Over:

The Dementia Researcher Podcast, talking careers, research, conference highlights, and so much more.

Dr Sam Moxon:

Hello, everyone, and welcome to the Dementia Researcher Podcast. Today our Food for Thought series returns and we’re going to be finding out if we can use diet and nutrition in the fight against motor neurone disease.

Hello, I’m Sam Moxon. I’m a researcher at the University of Birmingham and I spend a lot of time looking into ways we can improve our brain health with what we eat. We’ve already heard a lot about dietary approaches in preventing things like Alzheimer’s disease, but what about motor neuron disease? Helping me get to grips with this is Amber Sewell-Green, accredited dietitian and PhD candidate at the University of Queensland Faculty of Medicine. It’s an honour to have you here, Amber. Welcome.

Amber Sewell Green:

Thank you so much for having me.

Dr Sam Moxon:

Yeah, I’m really looking forward to this discussion. So, let’s get into it, shall we?

Amber Sewell Green:

Absolutely. Ready to go.

Dr Sam Moxon:

So Amber, I think a good place to start is with very simple questions. So the first question I like to ask people who come onto the show, because we talk so much about food and it’s the focus of our show, that’s why it’s called Food for Thought, and we’re looking at ways to improve our health by taking small steps with the things we put on our plate and they say the most important meal of the day is breakfast. So, the first question I like to ask people is, what did you have for breakfast today?

Amber Sewell Green:

All right. I’m a little bit of a creature of habit Monday to Friday. I definitely don’t mind going out for a good breakfast, but I myself have been plant-based for going on eight years. So usually, and probably even if I wasn’t plant-based I’d do a similar thing, I’m a big fan of muesli, so different kind of grains in there. I always try to include seeds, whether it be pepita or pumpkin seeds, chia seeds, hemp seeds, sometimes peanut butter if I feel like it, usually some oat milk, and whatever fruit I have on hand. So, at the moment we’re tropical, so we have some really good honeydew melon and really good mango. So that was my breakfast.

Dr Sam Moxon:

That sounds great. Mango is my favourite fruit. I love having mango at breakfast.

Amber Sewell Green:

So, in season at the moment and so juicy.

Dr Sam Moxon:

Definitely not in season in the UK, but I still enjoy it. So, the first question I want to ask you that’s more research focused, lightly research focused is, could you tell the listeners a bit more about yourself? Who you are, what your research involves, and how you got there in the first place? What inspired you to go down the route that you’ve gone down?

Amber Sewell Green:

I’ve been an accredited dietitian for around eight years now. I have had the fortune, or good fortune, to be able to work in the plant-based nutrition space. Didn’t think that was going to be so much of a possibility, but it has been, and it’s been an absolute delight. Mainly worked in private practises. I’m more involved in preventative and lifestyle changes, so always worked in that private practise space, but also taught at community college, practical tips, a little bit about cooking and a little bit more interactive group classes, worked in medical centres, and I’ve always had a passion to eventually end up looking at nutrition for brain and the mind because something that’s become very clear to me is you can’t really treat the body without the mind. And we have so many wonderful advances in giving someone an entirely new heart virtually if we need to, but we really are behind in terms of we can’t really do the same with the brain and the mind.

So I really see that, especially with all the stresses that have occurred in the last few years particularly and when we combine that with things like social isolation, that tends to cause changes in the brain and I think we’re going to see a big rise in more brain-related medical concerns coming up, especially as we’re living longer, our bodies can hold out, but our mind doesn’t seem to be doing the same. So, because I see changes in mood and mental health, increased rates of things like neurodivergence and also increased rates of things like neurological diseases of ageing, or NDAs like dementia and motor neuron, I thought, okay, it’s going to be really important to be at the forefront of this shift in medicine.

So about two years ago, I re-enrolled to study neuroscience. I did an accelerated course over two years instead of three, which was silly, but taught me very quickly. And then I ended up enrolling in a PhD in motor neuron disease. So that’s where I’m at. It’s been about a year and that’s where I was able to head over to Switzerland recently. So, it’s an exciting field, but it’s definitely one that is behind and that we’re having to pave a lot of the research, which I think was surprising. So that’s a bit about me.

Dr Sam Moxon:

Well, you say it’s still a bit behind. The good thing is I think we’re starting to catch up a little bit. So, we saw headlines in the UK earlier this year that dementia rates are predicted to double, and it was tied directly to obesity. So, we’re sort of gaining more of an understanding that those environmental factors do have a big impact on our brain and a big one is diet. But before we get into that, this podcast, speaking, is listened to by researchers but this particular Food for Thought series is starting to get public attention. And so, we have members of the general public listening who are interested in finding out more, that have family members who have dementia, or they want to learn about strategies that they can do to reduce the risk of dementia. And we’ve mainly spoken about Alzheimer’s disease, but today we’re going to talk about motor neuron disease. So, for anybody who’s listening who perhaps isn’t aware, could you spend a short amount of time talking about what motor neuron disease actually is and how it may differ to something like Alzheimer’s disease?

Amber Sewell Green:

Absolutely. So, motor neuron disease, and it’s also sometimes called amyotrophic lateral sclerosis or ALS, is that disease we’re most familiar with people like Stephen Hawkins who had the disease and did a lot of work in the field, or things like the Ice Bucket Challenge that went viral globally. So, this disease is a disease where the types of cells in the brain, called motor neurons, so the motor neuron, the motor part of the brain and then the other types of motor neurons, the ones in our muscles, they basically degenerate. So, you end up with problems with the brain, problems with the muscles, and essentially the brain can’t speak to the muscles, so slowly the body’s muscles will die off and it’s quite a devastating disease. There’s a very broad spectrum. So, it is a spectrum of disorders.

Amyotrophic lateral sclerosis, or ALS, is the most common one that involves both the motor neurons in the brain and in the spinal cord or the muscles. But there’s other forms that affect mainly the brain or other forms that affect mainly the muscles as well. It’s what we call a very heterogeneous disease in the sense that there’s a lot of difference in this spectrum, typically because it’s so devastating, people do die within three to five years of it, usually because the muscles for respiration or breathing are the last to go. But some people do live 10 to 12 years and that’s why we can’t assume that everyone’s the same. And I think there needs to be a really big push for not only looking at how to improve survival or prevent it, but also look at how we can improve the quality of those years lived as well because it is different.

Dr Sam Moxon:

It’s a very physical disease, isn’t it? Especially compared to something like Alzheimer’s disease, which can manifest primarily in a more cognitive way. Motor neuron disease is extremely physical, isn’t it? The effect that it has on the patient.

Amber Sewell Green:

Absolutely. And mind you, there is that cognitive element. There is what’s called an ALS FTD spectrum as well. So there seems to be some cognitive involvement, but you’re right, for the majority of people it’s that very, your mind is totally sharp, but your body is kind of deteriorating.

Dr Sam Moxon:

Yeah, almost failing you in the worst possible way. And it’s sort of tragic in the same way as Alzheimer’s disease. Although with Alzheimer’s disease, we have seen a few recent breakthroughs come through regulation, which are focused on acute treatment, which perhaps is not the best or not the best source of treatment at the moment, we’re looking at more prevention being powerful and motor neuron disease is the same, isn’t it? We have no cure. And so, to frame this discussion, where does diet sit in the framework of motor neuron disease? Is it similar to Alzheimer’s disease where this is something we can use more as a preventative strategy, but can it also improve quality of life for someone who’s diagnosed as well?

Amber Sewell Green:

I definitely want to be able to re-answer this question again in five years and give you more information on that, so please watch this space. But from what I’ve been researching, both in my own studies and just throughout the literature, it does seem like there’s a bit of both. You definitely have this prodromal phase 10 to 20 years before the disease actually hits where we definitely see lifestyle factors playing a difference. And that is seen throughout the literature. Your classic metabolic storm or higher levels of things like total cholesterol and LDL do seem, or that LDL, I call it lousy, but the type of cholesterol that we don’t want to see rise in our blood tests, which does seem to be related to increased risk of actually developing ALS.

And we’ve also got researchers out there that have now found it’s very much a gene environment interaction. Genetics only account for maybe 10% of this disease, 90% of cases are what we call sporadic, or we don’t really know why they’re occurring. But even within that 10% of genetic or familial cases, there’s huge amounts of difference. And even in genome-wide association studies, we see huge amounts of differences which do suggest that it’s a really complex interplay between our genes and the environment triggering very complicated cascades. And that definitely seems to have a metabolic involvement.

There’s also a researcher based in the UK, [inaudible 00:10:08], who’s done a lot of work finding that there’s six step processes, so six key things that need to be triggered in order to develop the disease. And if you have those four genes, you may have four of six, but that’s not the total six. So there definitely seems to be that lifestyle element in the preventative stage.

But once you have the disease, there also seems to be a lot of metabolic involvement. We know that the body seems to need more energy and the mitochondria, the energy units of the body, seem to require a lot more energy. There are cases where people become hypermetabolic, up to 50% of people with ALS can develop an increased metabolic load or need of the motor neurons. And if people can eat enough food, there’s a very different outcome compared to if people can’t meet those higher energy demands. We see switches from glucose as our body’s preferred fuel source, carbs, we see switches to fat being used as a fuel source, and so there’s clear changes there. But with that happening for a long time can induce inflammation in the body or increase in what we call reactive oxygen species. And we know that if someone is malnourished, which affects up to 50% of people, we say about 15% to 50% of people with ALS can develop malnutrition. It’s linked to 7.7-fold increased risk of earlier death.

So clearly once you have the disease, if you’ve got any amount of weight loss, even people in actually a healthy weight range, they kind of almost need to have a buffer of being a little bit overweight. If they’re not in that slightly overweight category, they die a lot faster and they experience functional decline a lot more rapidly. So there seems to be a really clear role of nutrition both during the disease and in the preventative space, which is why I think there is a lot of promise for nutrition in this field.

Dr Sam Moxon:

So, it sounds almost like the nutrition is in constant cycles both before and after diagnosis. The nutrition is critical throughout the whole process. I think that’s quite fascinating to hear. And so, what strikes me there is we hear this story so often with chronic disease, and there’s a physician you may know called Michael Clapper who uses the phrase that genes may load the gun, but the diet, the lifestyle, the environmental factors, they pull the trigger. And so, are there any particular, let’s say, bad nutritional elements that seem to put you at higher risk? The same way we see with saturated fat being a risk factor for Alzheimer’s disease, are there certain foods that you should be avoiding if you are perhaps at higher risk or want to reduce your risk of developing something like motor neuron disease? Or is it more about a more widespread approach of just trying to be healthier in general?

Amber Sewell Green:

I would say it’s a combination of both because at the end of the day, nutrition is a synergistic process, and if we start to cherry pick nutrients in isolation without looking at them at the whole picture, then we can start to skew the way that our body actually works. So, in lifestyle factors, we’ve definitely found things like smoking and things like when you are obese before getting ALS, at that 10-to-20-year phase, then you’re more likely to get the disease. That’s when we see high levels of total cholesterol and triglycerides and LDL, those more saturated fats that you described, linking to increased risk of developing the disease.

But once you’ve triggered it or switched it on, which seems to be maybe 10 years before the disease, the reason I’m hesitant to answer that is there seems to be a switch and everything that we know about health seems to flip. All of a sudden what we’d consider to be helpful cholesterol, our HDL, the one that takes our cholesterol back to the liver to be processed, if you’ve got high levels of that, it suddenly seems to be a risk factor once you get the disease. Something’s going on where our body suddenly needs to use fats and needs to use them quite heavily.

And maybe it is because the brain and the muscles rely so heavily on fats and if the body has got to a point where there’s insulin resistance or it can’t use carbohydrates effectively for energy, our body is going to need something. It’s going to need something for energy, and it might need both different types of fats, maybe more of the unsaturated ones, those ones that we’d get from different seeds would get from things like seaweed or our omegas that we describe seem to be protective. But it might also be that a lot of nutrients, fat-soluble vitamins, A, D, E and K and another one called choline, rely on fats. So, if we’re going, “Okay, I’m going to completely strip the diet of fats to avoid motor neuron disease,” we might actually be depriving ourselves of a lot of the nutrients that our brain and muscles really need to combat those metabolic changes going on.

So in essence, I would say try to follow those healthy lifestyle principles at this stage, trying to keep cholesterol levels in norms, trying to increase the types of fats that we consider to be nutrient rich, our avocados, our nuts and seeds, our omegas in whatever way you want to get that from. That’s also possible from things like algae and also trying to maintain a reasonably healthy weight and monitor what’s in your environment, at this stage, seems to be that protective approach. And I’m happy to link an article talking a little bit about some of the preventative or some of the factors that they’ve found that are listed in increasing the risk of developing ALS as well for further reading.

Dr Sam Moxon:

So, it’s interesting you talk about that switch post development of the good fats no longer necessarily having the benefit. And we had a guest on recently who was talking about ketogenic diets and almost being a strategy to bring in after Alzheimer’s diagnosis because of the changes in metabolism. And it’s got me wondering if there’s a similar thing going on here where the body’s need for different fats changes after a diagnosis like this.

But I’ll come back to that later. So I want to go back to, let’s say we’re in the preventative stage, so that 10 year window before something is triggered, is there a particular type of diet that can tick the boxes easily that people perhaps should think about moving more towards or adapting the principles of in their daily eating habits to help protect against something like this?

Amber Sewell Green:

When it comes to dietary style, I always say take care that nothing looks too extreme. If you’re really going extreme with your macros or trying to cut out food groups or trying to really home in on one thing, it’s usually kind of a disordered eating style packaged up and wrapped up in a present. So, I do say be very careful of anything that looks so extreme and really isolates or cuts things out.

But when we’re looking at a balanced dietary perspective where you’re getting in a full range of nutrients and the things that might protect the motor neurons, which are things like anti-inflammatory properties, then there’s two kind of dietary styles that come into mind that have been linked to improved brain health. And that might be one side is the kind of Mediterranean style of eating and the other style is the mind style of eating.

Now both of those actually can be classed in terms of plant-based nutrition because the benefits of both of these styles is they move away from your high consumption of animal products that might promote inflammation through various means and really focus on whole foods, whole grains, fruits, vegetables, nuts and seeds, and including plant-based proteins in the protein groups. So you’ll see this dietary style is not particularly low fat either because it has those whole food fats coming from things like avocados, nuts and seeds, olives, but then you’ve also got that whole grain element which is going to come with lots of B vitamins that support processes like methylation in a much more natural way rather than the kind of ground up flowers that might be fortified with nutrients in a way our body may not be able to break down so efficiently.

You’ve got all of your antioxidants and all those anti-inflammatory components and vitamins and minerals in there that are coming back to what I say, do be careful that we’re still including whole food versions of fats and particularly with a focus on omega-3s. The more I look into and treat people with things like multiple sclerosis or dementia or motor neuron disease, I do see that increased need for omega-3 fatty acids that sometimes can get ignored or overshadowed or be debated heavily in the plant-based nutrition realm. And they do say whether it’s coming from an algae-based supplement or whether you’re really focused on seaweeds or what have you, really do emphasise maintaining that as an element in that preventative and longevity space as well.

Dr Sam Moxon:

Is that the same omega you can get from something like a flax seed or is it a different omega?

Amber Sewell Green:

Yeah, yeah. So, omega-3 fatty acids can have a short-chain version, alpha-linolenic acid, which can come from things like flax seeds and chia seeds, but they have to be ground up essentially. If you don’t grind them, they’ll kind of go out the same way that they go in, and they also oxidise quite quickly. So, we’re not looking at grinding up a whole bunch of them and then having them there for the week. We’re looking at throwing them into a smoothie and letting them be ground up instantaneously.

There are cases where, say through pregnancy and breastfeeding or after a certain age, they say roughly 60 to 65, you may find that conversion of alpha-linolenic acid to direct long-chain omegas like EPA and DHA and DPA a little bit trickier. So, if you know that you have genes associated with motor neuron disease or associated with those neurodegenerative diseases of ageing, I usually say try to get your direct omega-3s or be a bit more focused on getting the direct ones, whether it be from foods or from supplements.

And here, I’m personally a huge fan of seaweed or algae. Fish are rich in omega 3, and I will be completely objective with that. They are high in that, but I’m also not a huge fan of how we’ve treated our oceans. And the downside of that is fish are also a big sponge for what we put in our oceans, including things like PCBs, heavy metals-

Dr Sam Moxon:

Microplastics.

Amber Sewell Green:

Microplastics, as you mentioned, pharmaceuticals. So, you may be getting your omega-3s, but it may be packaged with a whole bunch of other things, which could be that little switch that switches on that genetic factor as well. So, algae being a plant has filtration aspects in there, you’re getting all the wonderful omegas, which is where fish would get their omega 3, but you’re not seeing it packaged with as many of those extra nasties that might be in the ocean as well.

Dr Sam Moxon:

Okay. So, before I move on to the next wider question, just another quick one, is saturated fat thought to be a problem for motor neuron disease risk or is there not a study showing a connection between those at the moment?

Amber Sewell Green:

Leading up to, the saturated fats would be what increases or drives that LDL cholesterol, the type of cholesterol that goes from the liver and gets deposited around the arteries and slips in, but this is where I say everything doesn’t really make sense and then we see a switch in that about 10 years. So that, all of a sudden if you’ve got low total cholesterol or triglycerides or low LDL, it seems to make the whole disease process faster. And that’s where, at the moment, I would be hypothesising or my thoughts are if the body can’t use glucose as a fuel source and it suddenly needs that fat for extra energy, if you don’t have any there, then the motor neurons are going to struggle and kind of die off faster or degenerate faster.

And that’s actually a lot of what my PhD is focusing on is actually looking at the different subtypes of fats in the blood and in the diet and see if we can find a prognostic panel. So, we may find that once we have the disease, we actually, like you suggested, may need a higher fat diet. I’m definitely not an advocate for ketogenic diets, but in this case, I try to be objective as a researcher and say the brain and the muscles seem to need. And they actually, the muscles’ preferred fuel source, they do actually drive off fat, so they may need these types of fats. But even then, when you’re just giving those types of fats, long term it creates reactive oxygen species which can actually damage the motor neurons and trigger apoptosis or cell death.

So it may be that we need those types of fats, but we need them in a more Mediterranean style, or we need them more from say coconut combined with other fruits and vegetables and antioxidants so that we can actually spare that production of reactive oxygen species and actually promote. So, it’s still a system, it might be yes, we need those saturated fats when someone gets the disease, but we need them in a form that comes with lots of other vitamins and minerals and anti-inflammatory properties to actually help the cell itself and help the neurons.

Dr Sam Moxon:

It’s got me thinking as well, it sort of makes sense when you think about the fact that the cells we’re talking about, neuronal cells, muscular cells, their energy demand is huge, and that energy comes from the food that we consume. But then it’s also, I like the phrase food is not just calories, it’s information and it sort of has this big impact on our body and one of the big places it impacts is in our gut and our gut microbiome. And we now know so much more about the fact that that sort of culture of trillions of microorganisms in our digestive tract doesn’t just affect the way we digest food, it affects everything. And we know there’s links between the microbiome and Alzheimer’s disease. Have there been any suggestions that the microbiome may be playing a role in motor neuron disease as well? Or is that still a fairly new thing to be looked at?

Amber Sewell Green:

Our lab did try to actually investigate that, took so many stool samples that I’m sure they’re slightly scarred by this stage, and did try to look into it, but we’re clearly missing some answers with motor neuron disease. Because again, everything we go, “Oh, this is healthy,” seems to be absolutely flipped in motor neuron disease. And then the studies they found is that the types of gut bacteria that normally associated with poor health seem to be protective. Something is going on here and they couldn’t find conclusive evidence.

So, I wouldn’t say rule out the role of the microbiome. I definitely think it would have its place, but we haven’t figured out the right way to analyse it or we haven’t got conclusive results at this stage. So, I’d say there’s nothing I can specifically say at this point. I wouldn’t be surprised if it does come out, but I think we’ve got to figure out more about what’s going on underneath before we can tackle that question properly.

Dr Sam Moxon:

And I suppose the added difficulty is if you’re looking at patients and looking at the microbiome and you see changes versus healthy patients, you don’t know whether that’s a result of malnutrition from disease or change in dietary habits or if they are causative and finding out the relationship there can be quite difficult, because that was a big question about Alzheimer’s disease; is it because it’s hard to get patients to eat? Or is it because those gut bacteria have changed and that are driving the disease? And that makes it quite difficult.

If you don’t mind then, I’d like to move forward to post-diagnosis. Have you seen any sort of evidence of, I know we can’t cure this, but any improvements in quality of life when diet is included as part of a sort of, I hesitate to say therapeutic, well I guess it is that we are talking therapeutic, but have we seen improvements by changing people’s diets post-diagnosis, longer life or something like that?

Amber Sewell Green:

And I think we’re definitely on this amazing precipice where five years ago people weren’t interested in this topic and now it’s really only in the last five-ish years or so that it started to gain momentum. So, I’d say there’s definitely going to be more and more coming out, and this is a really exciting time as this literature starts to build. So I think if we come back in five years, I’m going to be able to tell you a lot more, but there’s definitely some preliminary findings that are coming out regarding improving things like fatigue and mood, slowing rates of decline, which in motor neuron disease is something called the ALS FRSR, a functional rating scale that looks at all the different symptoms and how quickly or rapidly someone is declining in the function of different parts of their body. So that’s used as a functional marker.

And we use something called Delta FRS, which is the overall rate of functional decline. And the other part that can be a marker for looking at how someone is declining is their respiratory function or their forced vital capacity. So, I mentioned that ultimately death is because the lungs don’t work anymore. So, if we’re seeing the lungs decline faster or slower, that can tell us how quickly the disease is progressing or how impaired someone might be feeling.

So, there are a few interesting studies I actually want to highlight which talk about the propensity of diet. We know that, before I go into them, what we call PEG, or a type of feeding which is done through a tube. If someone can’t eat properly because they’ve got involvement of their throat muscles or their vulva muscles, if they are provided with PEG nutrition, they tend to do a lot better in terms of they live longer, they progress slower, but we’re slowly trying to build upon if it’s not that kind of, I guess, artificial nutrition, what can we do in terms of the dietary element?

So, one of the studies I wanted to highlight is a study by Nieves and colleagues. This was done in 2016. I really love this because it’s something called a multi-centre study. So they looked at 16 clinics in the US from 2008 to 2013, over 27,000 people, but in the end there were around 200 people, sorry, 300 people with ALS and they looked at nutrition factors and they found that when someone has motor neuron disease, higher intakes of antioxidants, so these are the anti-inflammatory nutrients, and particularly a one called carotenes, which are your orange coloured pigment found in fruits and vegetables and also in green fruits and vegetables. It’s just that the carotene is often masked by the gut green chlorophyll that’s over the top, so our green and our orange fruits and vegetables, this was associated with higher ALS FRSR scores and higher forced vital capacity.

Now, with these scores, you actually want the scores to be as high as possible and the more disabled someone is, the lower their scores will become. And the same with forced vital capacity, you want as a high a percentage as possible, meaning the greatest amount of lung function. And as someone gets more disabled or loses their lung function, their forced vital capacity will decrease. So, fruits, vegetables, antioxidants, and carotenes were associated with slower decline in function in terms of the lungs and overall. And this can make a huge difference because when we’re talking decline, this is someone’s ability to speak and communicate. This is someone’s ability to write or lift or move things. So that, to me, is really important in terms of quality of life, especially when we’re looking at productivity and normality. So that, to me, is one of the first instances that start to show, okay, diet can have an impact.

This was recapitulated in a more recent study in Korea by Yu and colleagues, and this was in 2020, and they did look a little bit at microbiota, but they were more looking at terms of diets and 24-hour dietary recall. And they looked at fibre from five different food groups: from vegetables, fruits, grains, legumes, and nuts and seeds. This one, again, was a large study, so they had a few hundred people. So, it was a decent power in this study. So, what they noted is that the Delta FRS values, so with this one, you want the Delta FRS to be small to show a smaller change over time. If your Delta FRS is big, it means that that change is happening really, really quickly and someone’s declining really fast. If it’s a small Delta FRS, then they’re declining slowly and living longer. So, they found that people with the lowest Delta FRS had the highest intake of vegetable fibre intake. And that’s something I found really interesting. So, they also found-

Dr Sam Moxon:

Yeah.

Amber Sewell Green:

Yeah.

Dr Sam Moxon:

I’m just thinking, just to quickly, because something’s popped in my head there. You say the vegetable fibre, it goes back to the gut microbiome. We know vegetable fibre produces bacteria that produce butyrate, and that’s neuroprotective.

Amber Sewell Green:

Absolutely.

Dr Sam Moxon:

Which just got me wondering about that.

Amber Sewell Green:

So, this is why I say we are not conclusive with the gut microbiome, but I predict that we’ll find better ways to study it, maybe we’ll find more about ALS and be able to target the right question. So, I wouldn’t rule out the gut microbiota, I’d just say that we’re still figuring out the best way in order to actually test this hypothesis. So, I think there’s definitely potential still there. And this study also found that higher vegetable fibre intake was negatively correlated or negatively associated with inflammatory markers. So, there’s one called pro-inflammatory cytokine or interleukin, there’s interleukin 6 or IL-beta and another, chemoattractive protein-1. And this was in the cerebrospinal fluid, so the fluid that’s going around the spine and around the brain.

So, this shows that the vegetable intake was actually having an impact on inflammation, and we know that inflammation is a big part involved in the death of these cells, these motor neurons as well. So, they also found correlations with grain, the kind of fibres from grains as well.

So these two studies show that plant foods have different elements in them, particularly from vegetables, but we have found other studies showing fruits and grains as well have nutrients in the anti-inflammatory effects and are directly affecting the way that someone would be, I guess, declining in terms of their function and especially in their lung function.

There’s also, as you mentioned briefly, a few vitamins and minerals that have been associated. So, I’m happy to talk a little bit about these, but I’d say it’s still a bit of a watch this space kind of story.

Dr Sam Moxon:

Okay. Yeah, definitely. Yeah, I’d love to hear a little bit more about that. Yeah.

Amber Sewell Green:

All right. So, I guess, one of the things I like to highlight with this is that people are looking for a way of including nutrition and lifestyle. Because right now this is a disease where once you’re diagnosed, there’s not much you can really do to help yourself. And if we find a way that we can say, “Hey, eating more of this would help,” or “Following these guidelines would help,” it gives someone, I guess, a sense of control over their health, but also means that they can actually participate in eating, which itself has so many psychological and sociological benefits of just sitting down and sharing a meal.

So, we know that there was a study of more than 600 types of… Sorry, a study of over 6,000 people and it had over 7,000 medical records. And they found that more than half the people were using vitamins, supplements, different dietary styles, but the problem is because these weren’t evidence based, they didn’t really have positive benefits over the placebo. So, finding evidence-based nutrients is going to be really important. And what we have found so far in our literature is that there are certain vitamins and minerals, so particularly vitamin D and a little bit as well in vitamin A and E, our fat-soluble vitamins, does seem to have positive benefits. But if we’re finding a bit of difference in the literature, it can be that evidence is more found when its food based rather than supplement based.

We also seem to find that vitamin C and a few of our B vitamins, like vitamin B12 is involved, and that might be because vitamin B6, B9, and B12 is involved in a process called methylation in the brain that helps our cells. So that could be involved. But what we’ve really seen to find is that polyunsaturated fatty acids are particularly helpful in terms of once you’ve got the disease. And I’m starting to see that. Next year, I don’t want to say too much because it’s to come out, but it will be by next year, but sometimes this year I’m looking at bringing out a review on the evidence of different types of fats in motor neuron disease, and we see the strongest conclusive evidence is coming out around the polyunsaturated fatty acids.

Dr Sam Moxon:

It’s interesting you talked about food versus vitamins because our first guess on this show was Neil Barnard, and he talked a bit about vitamins and Alzheimer’s progression and how with things like A and E and the kind of things you would get from things like nuts, it’s much more beneficial to get them from the food than from supplements. And all those vitamins you talked about then, all the important nutrients, it’s so easy to get on a plant-based diet, including B12, which is the stick that’s often used to beat a plant-based diet, but it is possible to get B12 and that kind of thing.

And so I think what I’d like to ask next is, if someone’s listening to this and they may be wanting to make some of those dietary changes and move towards getting more plants on their plate and trying to move towards a healthier lifestyle, what advice would you give them? What’s a good place to start to make a change like this and make it a sustainable change that they can stick to?

Amber Sewell Green:

And that’s a really great question. What I would say is, firstly as a tip in any kind of habit change, it’s about consistency and not perfection. Try not to, if you’re feeling overwhelmed by doing a total 360, look at small changes that you can make and build upon. Maybe it’s a meal once a week, maybe it’s a day once a week, maybe it’s trying one new recipe a week. But the other part I say is focus on what you’re including more of rather than what you’re taking out. If you’ve decided you’d like to eat more legumes in place of meat, don’t focus on, “Okay, I’ve got to take out the chicken. I’ve got to take out the fish.” Focus on, “All right, what’s a new way that I can learn to use something like tofu? What’s a new way that I could learn to use chickpeas? What’s a new way I could learn to incorporate nuts?” So, look at what you’re focusing on including more of, and that’s going to be far more inspiring than what you’re taking out.

And also have a look at what nutrients. So, say, for example, I see a lot of people, maybe they decide that they want to swap to dairy alternatives, and they take out yoghourt and put in a coconut yoghourt. And that’s all well and good, that yoghourt is going to have similar flavour profiles and to kind of act in the same way a yoghourt would in that dish, but you’re not necessarily getting the calcium from that type of yoghourt. So, you might look at, “Okay, what are some different ways to get calcium?” And that’s where there’s all these different ways we can get them from green leafy vegetables, we can get them from figs of all things, we can get them from certain nuts like almonds and sesame seeds, we can get them from soybeans. So, it’s just about knowing, okay, if I’m going to take something out, I may put something back in that’s kind of texturally and food based very similar, but am I getting the nutrients? And if not, what’s another way that I can incorporate that into my day?

Dr Sam Moxon:

Yeah. And I think the message that you see a lot now as well from people who are trying to promote this type of living is to try and get 30 different plants a week, and that can include things like herbs. And that sounds like a lot, but if you make curry or chilli or something like that, if you include in the herbs, you can get 10 or 15 in that dish.

Amber Sewell Green:

It’s actually surprisingly easy. There’s a wonderful, I think it’s an app called Eat the Rainbow that sometimes I use for my patients just to start to promote that. And that is because of the diversity of microbiome. And that’s a lot more linked to, we know a lot more research with mental health that the greater amount of plant foods, the more diverse our microbiome is, and then there’s a lot more evidence around benefits for mental health in terms of that.

But you would be surprised, by the time you include, say you decide to chuck in quinoa for a change and it might be a tri-coloured quinoa that’s got a white, a black, and a red, you’ve already got three colours and three different versions of different plant nutrients in there. If you add just some onion, that’s one. We often actually exclude, we think, “Oh, it’s white or it’s brown, so it doesn’t count.” Those are plant nutrients in there, quercetin, myricetin, all of these are actually different types of antioxidants. Just because they’re not a bright orange or bright green, then you’ve got some tomatoes, maybe something green, maybe a carrot, and then you chuck in a legume and you’re already looking at getting, by the time you add a couple of spices, close to 10, a third of your weekly target in literally a single meal.

So, I think you’re absolutely right. The second we even just start to make some meals from scratch, we can get all these different colours in and it’s actually very, very easy.

Dr Sam Moxon:

Yeah, definitely. And it’s a nice way to eat as well. So, I think a good question to finish on is a summary. So, what do you think, someone who’s listened to this, what should their main take home be from this discussion, do you think?

Amber Sewell Green:

I would say, if you’re looking to take care of the health of your brain, definitely take into account lifestyle factors are important. Staying physically active, working on stress, but also having a diet that’s rich in lots of different colours, rich in plant foods, but also don’t be afraid of fats, but from a whole food perspective where we know that they’ve got that synergistic benefit.

And also knowing that if you are someone that gets the disease or someone that has the disease, that diet does play a factor, that maintaining nutrition is going to be really important in the health of these cells. And definitely highlighting particularly those polyunsaturated types of fats and definitely antioxidants, and maybe it’s working with a dietitian to try to maintain food and food intake as best as possible because it does seem to help with the actual quality of life in terms of protecting the motor neurons or the muscles and the brain for as long as possible. And also helping things such as mood and fatigue, which can be some of the greatest factors in disability in these diseases as well.

Dr Sam Moxon:

Yeah, really interesting well good luck with your study.

Amber Sewell Green:

Cool. And hopefully I can give you a bit more information in a few years.

Dr Sam Moxon:

So, everyone, I’m afraid that’s all we’ve got time for today. If you really enjoyed the topic, then you can visit our website, the Dementia Researcher website where you’ll find a full transcript from this episode, you’ll find links to the rest of the Food for Thought series, you’ll find some of the studies that we talked about, and you’ll also find the biographies of guests like Amber. And I’d like just to finish by saying thank you very much to you for joining us today, Amber. It’s been a fascinating discussion.

Amber Sewell Green:

Oh, I’m so glad and I’m happy to link my email and my website if anyone does have further questions or wants to keep up to date with this topic because it’s definitely something that’s going to be continued to be explored in an evidence-based way in the next few years.

Dr Sam Moxon:

And I think potentially worth coming back in a year or two’s time to see how things are going with this. I think everyone would want to hear a little bit more. But thank you all for listening. My name’s Sam Moxon. You’ve been listening to the Dementia Researcher podcast, and we’ll see you all next time.

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The Dementia Researcher Podcast was brought to you by University College London with generous funding from the UK National Institute for Health Research, Alzheimer’s Research UK, Alzheimer’s Society, Alzheimer’s Association, and Race Against Dementia. Please subscribe, leave us a review, and register on our website for full access to all our great resources, dementiaresearcher.nihr.ac.uk.

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