Protein Requirements for Muscle Preservation in Multiple Sclerosis

Protein is the building block of muscle, and maintaining adequate muscle mass is a cornerstone of functional independence for people living with multiple sclerosis (MS). The disease’s neurological impact, combined with common secondary issues such as fatigue, reduced mobility, and medication‑related metabolic changes, can accelerate muscle loss if nutrition is not carefully managed. This article delves into the specific protein requirements needed to preserve lean tissue in MS, explains the underlying physiological drivers, and offers practical, evidence‑based strategies that can be applied year‑round.

Why Muscle Preservation Matters in Multiple Sclerosis

• Functional Mobility: Muscle strength directly influences gait speed, balance, and the ability to perform activities of daily living (ADLs). Even modest declines in lower‑body strength have been linked to increased fall risk and loss of independence in MS cohorts.
• Metabolic Health: Skeletal muscle is a major site of glucose disposal and lipid oxidation. Preserving muscle helps mitigate insulin resistance, dyslipidemia, and the weight‑gain tendencies that can accompany reduced activity levels.
• Immune Modulation: Muscle tissue secretes myokines (e.g., IL‑6, irisin) that exert anti‑inflammatory effects. Maintaining muscle mass may therefore contribute to a more balanced immune response, which is particularly relevant in an autoimmune condition.
• Quality of Life: Greater muscle mass correlates with higher self‑efficacy, reduced fatigue perception, and improved overall well‑being—outcomes that are repeatedly highlighted in patient‑reported outcome measures for MS.

Physiological Factors That Alter Protein Needs in MS

Evidence‑Based Protein Intake Recommendations

1. Baseline Recommendation:
• 0.8 g/kg body weight/day is the minimum to meet nitrogen balance for healthy adults. For MS patients, this is generally insufficient for muscle preservation.

2. Adjusted Target for Muscle Maintenance:
• 1.2–1.5 g/kg body weight/day is supported by multiple clinical trials involving neurologically compromised populations. This range accounts for anabolic resistance and disease‑related catabolism.

3. Upper Safe Limit:
• For individuals with normal renal function, intakes up to 2.0 g/kg/day have been shown to be safe over the short‑ to medium‑term. Long‑term high intake should be monitored, especially in those with compromised kidney function.

4. Per‑Meal Distribution:
• Aim for 0.3–0.4 g/kg of high‑quality protein per eating occasion (≈20–30 g for a 70 kg adult). This dose maximally stimulates the muscle protein synthesis (MPS) pathway (mTORC1 activation).

5. Leucine Threshold:
• Approximately 2.5 g of leucine per meal is needed to trigger a robust MPS response. Foods rich in leucine (e.g., dairy, whey, soy) should be incorporated strategically.

Protein Quality and Amino Acid Profile

Key Takeaway: Prioritize high‑biological‑value proteins that deliver at least 2.5 g of leucine per serving. Combining animal and plant sources can improve overall nutrient diversity while accommodating dietary preferences or restrictions.

Timing, Distribution, and Meal Planning

1. Even Distribution Across 3–4 Meals
• Example for a 70 kg individual targeting 1.4 g/kg (≈98 g protein):
• Breakfast: 25 g
• Lunch: 30 g
• Dinner: 30 g
• Evening snack/supplement: 13 g

2. Post‑Exercise Window (30–60 min)
• Consuming 20–30 g of fast‑digesting protein (e.g., whey) after resistance training amplifies MPS and aids recovery.

3. Night‑time Protein
• A casein‑rich snack (e.g., cottage cheese) before bed provides a slow release of amino acids, reducing overnight catabolism.

4. Managing Fatigue‑Related Skipping
• Prepare ready‑to‑drink protein shakes or pre‑portioned snack packs that can be consumed quickly when energy is low.

5. Addressing Dysphagia
• Use pureed or blended high‑protein foods (e.g., Greek yogurt blended with fruit, protein‑enriched soups). Ensure texture meets the patient’s swallowing safety level.

Special Populations and Clinical Considerations

Integrating Protein with Exercise for Optimal Outcomes

• Resistance Training Frequency: 2–3 sessions per week, focusing on major muscle groups, is sufficient to synergize with protein intake and counteract anabolic resistance.
• Progressive Overload: Gradually increase load (5–10 % per week) to continuously stimulate MPS.
• Neuromuscular Adaptations: Even low‑intensity, high‑repetition circuits can improve motor unit recruitment, which is valuable for patients with spasticity.
• Recovery Nutrition: Pair post‑exercise protein (20–30 g) with 30–40 g of carbohydrate to replenish glycogen and further enhance MPS via insulin signaling.
• Hydration: Adequate fluid intake supports nutrient transport and kidney function, especially when protein intake is elevated.

Practical Strategies and Sample Menus

Breakfast (≈25 g protein)

• 2 large eggs scrambled with spinach (12 g)
• ½ cup Greek yogurt mixed with 1 tbsp chia seeds (13 g)

Mid‑Morning Snack (≈13 g protein)

• 1 scoop whey isolate mixed with water (20 g) or ½ cup cottage cheese (13 g)

Lunch (≈30 g protein)

• Grilled salmon (120 g) (25 g)
• Quinoa salad with chickpeas (½ cup) (5 g)

Afternoon Snack (≈13 g protein)

• 1 small apple with 2 tbsp almond butter (7 g)
• 1 hard‑boiled egg (6 g)

Dinner (≈30 g protein)

• Lean beef stir‑fry (150 g) (30 g) with mixed vegetables
• Small side of mashed sweet potatoes (optional)

Evening Snack (optional, 20 g protein)

• ¾ cup low‑fat cottage cheese with a drizzle of honey (20 g)

*For individuals with dysphagia:*

• Blend the salmon, quinoa, and vegetables into a smooth puree, add a scoop of whey protein, and season lightly.
• Use thickened liquids as needed per speech‑language pathologist recommendations.

Monitoring, Adjusting, and When to Seek Professional Guidance

1. Baseline Assessment
• Body weight, BMI, and body composition (e.g., bioelectrical impedance)
• Serum albumin and pre‑albumin (optional, as inflammatory status can confound)
• Renal function (eGFR, BUN, creatinine)

2. Follow‑Up Frequency
• Every 3–4 months, or sooner after a relapse, medication change, or significant weight shift.

3. Outcome Metrics
• Hand‑grip strength or dynamometry
• 6‑minute walk test (6MWT) distance
• Patient‑reported fatigue scales (e.g., Fatigue Severity Scale)

4. Red Flags Prompting Referral
• Unexplained weight loss >5 % in 3 months
• Persistent muscle weakness despite adequate protein intake and exercise
• Declining renal function or electrolyte abnormalities

5. Professional Involvement
• Registered Dietitian (RD): Tailors meal plans, addresses texture modifications, and ensures micronutrient adequacy.
• Physical Therapist (PT): Designs resistance programs compatible with neurological status.
• Neurologist/Physiatrist: Oversees disease‑modifying therapy and monitors for medication‑related metabolic effects.

Future Directions and Research Gaps

• Longitudinal Trials on Protein Dose‑Response: Most existing data are extrapolated from older adults or other neurodegenerative conditions. Dedicated MS cohorts are needed to refine the optimal gram‑per‑kilogram target.
• Leucine Supplementation Studies: While leucine’s role is well‑established in sarcopenia, its specific impact on MS‑related muscle loss remains under‑explored.
• Interaction with Disease‑Modifying Therapies: Investigating how agents such as ocrelizumab or dimethyl fumarate influence protein metabolism could lead to personalized nutrition protocols.
• Gut Microbiome‑Protein Interplay: Emerging evidence suggests that protein source (animal vs. plant) may modulate gut flora, which in turn can affect systemic inflammation in autoimmune disease.
• Technology‑Enabled Monitoring: Wearable devices that track activity and muscle function could be paired with dietary apps to provide real‑time feedback on protein adequacy.

Bottom line: For people with multiple sclerosis, preserving muscle mass is not a luxury—it is a therapeutic priority that directly influences mobility, metabolic health, and overall quality of life. By targeting a protein intake of 1.2–1.5 g per kilogram of body weight per day, emphasizing high‑quality, leucine‑rich sources, distributing protein evenly across meals, and coupling nutrition with resistance exercise, clinicians and patients can create a robust, evergreen strategy to combat muscle loss throughout the disease trajectory. Regular monitoring and individualized adjustments ensure that the plan remains safe, effective, and sustainable over the long term.