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S2E3 Lifestyle choices and their impact on MS with Dr Aaron Boster

Listen to S2E3: Lifestyle choices and their impact on MS with Dr Aaron Boster

A few episodes ago, Dr. Aaron Boster, an Ohio-based board-certified clinical neuroimmunologist specializing in MS, helped guide our listeners through the straits of making the right medication choices in MS. Given we are surrounded by temptations – from that delicious pint of ice cream to the lure of sleeping in instead of hitting the gym – we are happy to tap his expertise to help us understand the complicated calculus of how the lifestyle choices we make might impact MS and our overall health.


Episode transcript

Geoff Allix  00:00 

Support for the Living Well with MS podcast is provided by Overcoming MS, a global charity registered in the United States, United Kingdom and Australia, whose mission is to educate, support and empower people with MS, in evidence based lifestyle and medication choices that can improve their health outcomes. Please visit our website at to learn more about our work and hear directly from people around the world, about the positive impact Overcoming MS has made on their lives. Now on to today’s episode. In today’s episode, we will be talking about how lifestyle choices affect people with MS. For this episode, I’d like to welcome back Dr. Aaron Boster. Dr Boster decided he wants to become an MS specialist at the very young age of 12 when his uncle was diagnosed with MS and he now runs a very popular YouTube channel with literally hundreds of episodes and regular Q&A sessions covering every aspect of MS and I thoroughly recommend that you have a look this excellent resource. So Dr. Boster; welcome and one of the episodes of your YouTube channel that was particularly interesting was your 4for4 approach and I’d like to discuss this view and how lifestyle affects people with MS and how they can affect their disease outcome using lifestyle choices. 


Dr. Aaron Boster  01:26 

Thank you so much for having me back, it’s a pleasure to talk with you again and thanks for giving me an opportunity to talk about this 4for4 concept. The goal in clinic is to help someone be the most awesome version of them possible despite having MS. And it’s a fool in my opinion that thinks that you can accomplish that goal simply with a medication and when you boil it down, there’s a partnership, there’s a team trying to help someone with MS achieve their life goals and avoid neurological disability and to be the best they can be and it requires both the clinician to do their work and it also includes the person impacted by MS and their family, they have a responsibility as well. And so the 4for4 concept is a easy wave, at least conceptually for me, to think about the things that I’m hopeful that someone with MS will embrace, to help them be the best they can be. And there’s really four aspects that I try to talk to folks about. So the first one is to not smoke cigarettes. It turns out that smoking tobacco increases the risk to develop MS and if you have MS, smoking tobacco speeds up the disease course, in some studies by almost 50%. Now fortunately, if you stop smoking, it reverses this risk and so I would submit that smoking is probably the best way to make you get worse fast with Multiple Sclerosis. Now you would be amazed at Geoff, here in the United States of how many people smoke, and how many people with MS smoke and don’t know it’s bad for them, they’re unaware. And so you know, the number one thing I talk about in the 4for4 concept is the importance of not smoking. Now if I extend that a little bit, I would also like to include the fact that we have to think about other cardiovascular risk factors. My friend Gavin Giovannoni talks quite a bit about brain health and really, when you when you look at what we’re both discussing, it’s about avoiding other cardiovascular risk factors. So in addition to smoking, things like managing diabetes, and high cholesterol and high blood pressure, are also really important to slow down MS. And what I mean by this is, if you have uncontrolled diabetes, or uncontrolled high blood pressure, it actually makes people with MS get worse faster and so that’s all kind of encapsulated on the first piece of this 4for4 which is to not smoke. 


Geoff Allix  04:09 

I think a lot of people actually do think, because I’ve come across people, they’re saying, well, I’m not so worried about smoking, because I’m not as worried about lung cancer, I’ve got MS and I’m just worried about that. But actually, what you’re saying is that those factors that might be affecting whether your risk of heart disease, your risk of lung cancer, they’re actually going to directly affect your MS prognosis as well. 


Dr. Aaron Boster  04:09 

That’s exactly right. You know, and to talk about smoking a bit more. when you take some tobacco leaf and you light it on fire, and then you suck in the smoke into your lungs that is a very, very inflammatory thing to do. It creates a tremendous amount of inflammation in the body and it’s not limited to your lungs. And so there’s multiple reasons why smoking riles up the immune response, gets the immune response, you know, very, very active and that’s to the detriment of someone with an autoimmune condition. So you’re absolutely right, you know the public messaging is out there that smoking can cause cancer, or that smoking can increase the risk of a heart attack, those things are certainly true. But unfortunately, most folks don’t know that it can make MS worse and so that’s why I really feel that the first piece of being 4for4 in your fight against MS is to not smoke cigarettes. 


Geoff Allix  05:32 

And how about vaping if someone were vaping, would that be as bad or it’s not bad at all? 


Dr. Aaron Boster  05:39 

It’s an excellent question and I think that literally day by day, we’re learning more about vaping. So vaping tobacco is a new way of ingesting tobacco. And the upside is thought that you’re not combusting the tobacco, you’re not setting it on fire and breathing in the smoke, you’re simply heating it up so that the essential oils is not the medical term, but so that the particulate matters kind of turned into a vapor and then you breathe in the vapor and we don’t have good studies to tell us about the effects of vaping. Now, it would appear at first blush, that that’s better for you than smoking, except I don’t know that we completely know that. Now, given that I practice MS Neurology in the real world with real life human beings, I can’t wait around for you know, 30 years from now when we have that answer. And if I was proposed, someone smoking an analog cigarette today, versus vaping, I would ask them to vape, you know they’re not breathing in the same carcinogens and I think that there’s ways of helping people kick the nicotine habit through vaping. You know, and I’ve had some success in clinic where people as they buy new, I think they call it juice, you know, the liquid that you put in the vape pen, you can actually decrease the increment of nicotine and so I’ve actually successfully seen vaping as a way to help people transition, first off of analog cigarettes, and then ultimately off nicotine in it’s entirety. 


Geoff Allix  07:16 

So ideally, don’t smoke at all, but vaping might be a probably less harmful alternative, and might be a good way of actually getting off smoking completely. 


Dr. Aaron Boster  07:30 

Probably, yes. Yes, that’s right. You know, there are some developing concerns that when you vape, there’s some other chemicals that you’re breathing in, but I think to speak in generalities, you hit the nail on the head, if I had to pick between the two, I think that vaping might have an advantage over an analog cigarette. 


Geoff Allix  07:52 

Okay, and so what’s the next of your, your pillars or your, your 4for4? 


Dr. Aaron Boster  07:57 

So after avoiding tobacco, the second element in 4for4 is to exercise as part of your lifestyle. And so it’s fascinating that people with MS that exercise as part of their lifestyle fare better later in life than those that don’t. And there’s a lot of different ways of thinking about this. But let me just share a few with you. If you think, hypothetically, let’s take someone impacted by MS and we clone them. So we’re gonna have to get permission from their spouse and a bunch of other hoopla, but we now have two versions of the same human; Clone A and Clone B. And we give Clone A, daytime soap opera TV, and a chocolate cake. And we give Clone B, a treadmill and carrots and so we get back together five years later, and Clone A is deconditioned; they’re overweight, their cardiovascular system is not very in shape, their balance and flexibility is not super, but they have a great love of chocolate cake and they can tell you any trivia about daytime TV. The Clone B is now conditioned, they’re in shape, they have a strong core, they have strong legs, they’re flexible, their cardiovascular system is in tip top shape. And you have these two clones and then they both suffer the same attack of left leg weakness, they have an MS attack that hits their left leg. Clone A is seated in a wheelchair, hopeful they may recover one day, Clone B is limping and going to work. And all we did in this example, Geoff is we allow Clone A to become deconditioned and we pre habilitated Clone B and I won’t insult you by asking the obvious and if you were to pick who you’d like to be, of course, you want to be B and not A. So in this again, this has nothing to do with MS disease modifying therapies this has everything to do with lifestyle. You know, there’s a lot of invisible symptoms in Multiple Sclerosis and it’s the bane of many people’s with MS existence that quote, ‘honey, you look so good’, you know, to the casual outside observer, they you know, they have two arms, they have two eyes, they have two legs, they don’t look sick, supposedly. And yet, when you look at people with MS and you talk to them, fatigue, a pathologic fatigue is the most prevalent symptom and it’s the number one reason people leave the workforce. If you’re not impacted by MS, I’d submit to you, you probably don’t understand the degree of fatigue that someone with MS might experience, depression is twice as likely in someone impacted by MS than in the general population. There’s a plethora of other invisible symptoms, such as cognitive fog, or difficulty with cognitive processing, exercise ameliorates, all of those. So exercise has been shown to increase sleep quality, to improve energy levels, to decrease pathologic fatigue, to improve cognition, I could go on for quite some time listing the benefits of exercise, and it’s not a medicine, it’s free. And so it’s not easy to be impacted by MS and build exercise, I’m not suggesting for a moment, you just need to, quote, get off your duff and work out. But I do think that there has to be a constant and unrelenting effort towards being in shape.  


Geoff Allix  11:26 

Is there an advantage to types of exercise, so whether it’s cardiovascular or someone’s pumping weights, is there a difference? 


Dr. Aaron Boster  11:35 

In my opinion is the best kind of exercise for you, is the exercise that you’re willing to do long term. So we don’t have solid evidence that unequivocally proves that cardiovascular work is great and lifting weights is bad, that data doesn’t exist. And when you look at the clinical studies that have been done trying to study exercise, they’re not giant, largely powered studies, the way we see with MS Pharmacology trials. They’re normally small, single centered studies, which makes big sweeping statements or conclusions. But if you, for example, are passionate about yoga, and yoga is something that you can get yourself to do a couple times a week forever, man, I want you to do a lot of yoga. If you are a weightlifter and you love being in the gym, then that’s what I want you to do. Again, I practice MS neurology in the real world and until we have firm data that states that this is the answer that is the very best version of exercise, I am happy to have you do what you’re interested in doing. It’s my experience that if I asked you to do a form of exercise that you don’t like, you’re going to do it for about three weeks, and then you’re going to stop. And so I really feel like you have to find something that you enjoy. Now with that stated, there are certain forms of exercise that I think can be more palatable or more tolerable for people impacted by MS. Water is really special because in the water, you weigh less and so if you have a weak leg, which is you know, hard to to run on, you can probably walk in the water or swim in the water despite that weak leg. And if you have spasticity, the water seems to make the spasticity better. If you are off balance and you keep falling to the left, the water pushes back to the right. If you easily get overheated and short circuit when you get overheated in the water via convection, we pull the heat off your body. So sometimes I recommend walking laps in the pool or swimming or participating in a water aerobics or Zumba class. So that can be a really great way of exercising with MS. 


Geoff Allix  13:48 

I personally find that if I do a lot of exercise, normal exercise, walking the dog up hills and things, then it makes my symptoms worse. So in a short, not in long term, but short term for the rest of the day, I won’t be doing an awful lot of walking around. Because my legs are tired, but if I go for a swim in the morning, interestingly that doesn’t happen I actually feel better. So it doesn’t actually have that negative short term effect when I go swimming even if I’m swimming quite hard. 


Dr. Aaron Boster  14:23 

You bring up an excellent point. And another another important piece to that if I may, is the fact that we can’t approach exercise with MS the way that we did in primary school or in you know, High School. I talked about the high school mentality and so I harken back to you know the glory days of high school where if you can run a mile then you can run two miles and if your friend can run two miles well you sure as heck can run four, but if you stop exercising, even for a short period time you just stop everything. And one of the key elements to success with exercise and MS, is to incrementally increase what you’re doing and I’ll use your example of walking really hard with a dog up hills, and then having your legs not working right for the rest of the day. If you instead, for example, were to take very short walks, using the following day as your metric of success, if you could exercise in whatever capacity and the next day was a normal day for you, then I would submit, you didn’t overdo it. And it might not feel like you’re putting in good work, you know, you’re not really working out real hard, but if you slowly, incrementally increase that, there’s almost no limit to how far one can go and I think that’s an important point in the way that we approach exercise in MS. Sometimes it’s very challenging to ferret that out on your own and we leverage experts, such as neuro physical therapists to guide patients as they start their journey and exercise. I’m delighted to hear that when you swim, that, you know, it works great for you. And I think that’s fantastic, I hope that people listening to this podcast will contemplate what kind of exercise works best for them. 


Geoff Allix  16:14 

Okay, so really just go with the exercise that you will continue to do regularly, that’s the best exercise for you.  And your third pillar; Vitamin D, which you’ve actually expanded to encompass a healthy diet, we’ve had a session already on Vitamin D. So, just sort of briefly talk about Vitamin D, but also the diet aspect of it, because that’s probably the aspect that everyone takes from certainly from the OMS approach. So all my friends think I’m doing a diet and I have to say to them, it’s a bit more than doing a diet, but because it’s more visible they think, oh, well, he’s not eating unhealthy. I had a terrible diet before to be honest. I’m not eating the unhealthy food anymore it’s visible, they see it when I go to a restaurant, whereas they don’t see the other aspects of my OMS protocol or my MS treatment. So for your sort of third pillar how, what are your recommendations about diet and Vitamin D? 


Dr. Aaron Boster  17:29 

Absolutely. It’s something when someone’s diagnosed with MS, invariably, within the first conversation they asked about diet; is there a food that I should avoid? Are there certain things that I shouldn’t eat? And I start off by saying that there’s no diet regiment that has been proven to slow Multiple Sclerosis. Now, there’s a lot of books published that might tell you different, but I’m sharing that in 2019 when you look at the scientific studies, there is no study that shows that you can slow the disease down. But that doesn’t mean that the diet can’t impact and it most certainly has a giant impact in MS and it’s extending to energy levels into cognition into a bunch of other very, very important areas. Now, to get a level deeper, and we mentioned Vitamin D; low levels of Vitamin D pre puberty, increase a given individual’s risk to develop MS. You and I both live pretty far north of the equator and we don’t see a lot of sun in our respective countries. And as such, we both probably have relatively low levels of Vitamin D, because you get your Vitamin D from the sun, supplementing low levels of Vitamin D would appear to be protective against getting MS. And if you have Multiple Sclerosis, when I look at the breadth of data, supplementing low levels of Vitamin D is correlated with better outcomes. Low levels of Vitamin D, in specific do have an impact on the course of disease. And so we check Vitamin D levels in patients and if they’re low and for me low is under 50, then we supplement to push it up. But I have as you point out extended this third piece of being 4for4 to include other aspects of diet. And my opinion increasingly, is that as you figure out the right diet for you, I want people to avoid a couple of things. I strongly recommend avoiding processed foods and I strongly recommend avoiding sugar laden foods. So I’m increasingly becoming a really big believer of eating real food. Many red blooded Americans Geoff don’t eat real food they live off of soda or diet soda, and they eat fast food which isn’t actually food.  If you buy a cheeseburger from a fast food joint, and unwrap it and put it on your desk, several years later, I’m not joking, it looks the same. It doesn’t rot. It’s not real. It’s, you know, real food should spoil. And so, when people ask for diet recommendations, and they say, what about this? What about that? The one thing that I think is consistent that I really strongly recommend, is to avoid processed foods and foods with added sugar.  When my patients have embraced this, almost uniformly, they’re shocked, they come back and say, Oh, my goodness, gracious, my energy levels are better, I’m less depressed XYZ. And it’s really exciting for me when they discover this, again, it’s something that they control. Many of us fall into a lifestyle where we’re not really taking time to prepare properly, and to sit down and eat meals and we’re eating on the go and we’re shoving things in our mouth that aren’t actually food. 


Geoff Allix  21:09 

We have in the UK, there’s a doctor called Ranjan Chatterjee, who’s done some TV episodes for the BBC. And one of the things, he actually has a four pillar plan, which is not dissimilar, but it’s for general health. But one of the things he says about the diet aspect is to look at the number of ingredients, and he said, If something’s got more than five or six ingredients, then it’s a simple test, really to say that’s probably quite heavily processed. Rather than having to, you know, when you sometimes you turn things over the ingredients lists about 50 Ingredients long. And those are likely to be the culprit, something that’s heavily processed. Would that would you agree with that? 


Dr. Aaron Boster  21:56 

I agree with that. What I typically will tell people is if you look at the ingredients, and you don’t, you can’t pronounce the words, or you don’t know what the words are, that’s not food. So I like to eat things that have ingredients like; Apple, that’s just an it’s an apple, there’s no other ingredients, I’m holding a piece of fruit, it’s an apple. But if you look at an apple fritter, which is, you know, you buy in a vending machine, and you know, you look at the plastic at the back, and it’s got all the ingredients you’re spot on; Number one, it’s got 25 ingredients and number two, the vast majority of those ingredients are chemicals that you can’t pronounce. So I like his idea very much another way of thinking about it is, if you don’t know the words, then that’s probably not food. 


Geoff Allix  22:43 

Okay, thanks. So the OMS approach of eating a whole food based, low saturated fat diet is largely similar to your approach that that would be a sensible choice. 


Dr. Aaron Boster  22:58 

I think so, you know, you bring up a very important point before we move on. When you when you’re thinking about diet, we know that uncontrolled cardiovascular risk factors make MS worse. And so having a heart healthy diet has a dual advantage. Not only does it help with cholesterol and risk of heart attack, etc. but it also has a secondary benefit to someone with an autoimmune condition like MS. So I do embrace that concept, I think it’s an excellent recommendation for people impacted by MS. 


Geoff Allix  23:36 

And some people they think the lifestyle approach to MS precludes them from taking medication? And there are certainly a number of people who are treating if you’d like their symptoms with lifestyle choices, and no medication. But would you say that the fourth pillar of your 4for4, that medication is something that works alongside these other things, or is an alternative to the other approaches? 


Dr. Aaron Boster  24:10 

Yes, the fourth piece of being 4for4 is to take an MS medicine and make sure it’s working. If we could adequately control the disease without medicine, that would be fantastic and I would endorse that. But the reality is that these benefits are cumulative. And you know, it’s not like a piece of pie where you have this one or that one. We can do it all at the same time and I think that they complement one another. So you know, I sometimes say I’m not proud. I don’t care how we get you there but I want you to achieve your life goals. If you want to climb Machu Picchu or you want to finish your PhD, or you want to walk your daughter down the aisle 30 years from now, and that’s our goal. And I want to use every modality that’s currently available to help you achieve that goal. And so yes, I want people to not smoke. Yes, I want people to supplement Vitamin D and to pay close attention to their diet. Yes, I want people to exercise as part of their lifestyle, in addition to taking an MS medicine and making sure that it works. 


Geoff Allix  25:15 

Okay, that very much aligns with the OMS protocols. But there are some other protocols in the OMS approach. And one of those would be stress reduction, and specifically encouraging mindfulness or other stress reduction techniques and how would that fit with your 4for4 approach? 


Dr. Aaron Boster  25:36 

I think that that is a fantastic recommendation. And I wholly endorse mindfulness, I wholly endorse stress reduction. I hate it, when doctors tell people to remove stress, it makes me want to smack them about, because I don’t know how to remove stress, like, you know, clipping your toenails. Everyone has stress in even fantastic life events, such as getting married or buying a new home or getting a promotion, those are stressful events, sometimes some of the most stressful events. Nobody goes home at night, Geoff and says, hey, let’s get stressed out. You know, that’s not something you hear people say and so we know that stress can have an impact on MS symptoms. And to be the most awesome version of us possible, I think that we have to learn to manage stress to the best of our ability. Exercising as part of your lifestyle, affords us at least one avenue for stress reduction, because there’s excellent data supporting the idea that exercising as part of your lifestyle reduces stress. I as an allopathic doctor, or an MD was not formally trained in mindfulness, or the benefits of let’s say, for example, meditation. And yet, I am increasingly becoming enamoured with these concepts and my patients that are able to practice mindfulness, my patients that are able to work to reduce the stress in their life anecdotally, Geoff, they fare better, they do better. And so why would we not want to bring that to the table? I think it can only help us. You know, I think that’s probably true for human beings in general, but people impacted by MS probably have an additional benefit to learning how to manage stress in their life. 


Geoff Allix  27:22 

Okay, that’s really useful. And the final pillar of OMS, which you don’t mention is that it’s useful to apply some of these techniques to family members, because they have an increased risk of getting MS in the future. So is that a sensible approach? 


Dr. Aaron Boster  27:45 

I think it is, but for a couple of different reasons. So you don’t get to have MS by yourself, you know, you have MS with your village. And it’s my opinion that I want you to have the biggest village possible. And I volunteer to be a village member, you know, your clinician, your clinic nurse, the social worker, your spouse, your children, your parish priest, your neighbour, this is your village. And you don’t go through this life impacted by MS alone, you do it with your village. And so rallying the villagers to support you in a healthy manner is simply brilliant. And if you think that a care partner isn’t impacted by MS, you’ve never really had a frank conversation with a care partner. I was a family member of someone impacted by MS decades before I became an MS doctor, to tell me that my family wasn’t impacted by the disease is nonsense. And so I think there’s many reasons why it’s appropriate to apply these concepts of healthy living of exercise as part of your lifestyle, as clean eating whole foods, of not smoking, to the village members. Now, in addition to that, it’s true that family members of people impacted by MS have a slight increased risk to develop MS. And so it is very sensible to avoid tobacco and to supplement Vitamin D, for example. I think that’s an excellent recommendation. 


Geoff Allix  29:22 

Thanks very much again. And I’d like to just finish up by saying thank you for joining us and to again, recommend that people have a look at your YouTube channel because there are regular updates and a huge amount of resources available there. And as I said, literally hundreds of episodes and you can go back through and have a look and find huge amounts of advice on that YouTube channel. 


Dr. Aaron Boster  29:46 

Thank you, Geoff. You know, you can find me on YouTube just by typing in my name Aaron Boster MD is the name of the channel. You know, and it’s my goal to help people impacted by MS, to be the best version of them. I want to try to empower educate and energise people impacted by MS. Thank you for giving me the opportunity to talk with you today. 


Geoff Allix  30:05 

With that, I would like to thank you all for listening to this episode of Living Well with MS. Remember, there is a wealth of information at including show notes and an archive of all Living Well with MS episodes. Once again, that’s There you can also find OMS friendly recipes and exercise tips, connect with other OMSers in your local area through our OMS Circles program, and learn about the latest research going on in the MS world generally, and related to OMS specifically. I encourage you to register on the site, and stay informed about the latest news and updates. I also encourage you to subscribe to this podcast, so you never miss an episode. And please feel free to share it with others who might find it of value. Let us know what you think about the podcast by leaving a review and if you have ideas for future episodes, we’d love to hear from you. So please contact us via our website Thanks again for listening, and for joining me on this journey to Overcoming MS and Living Well with Multiple Sclerosis. I’m Geoff Allix and I’ll see you next time 


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