Preconception diet, fertility and MS

MS Plus acknowledges the traditional custodians of the land this podcast is recorded on, the Wurundjeri people of the Kulin Nation. We pay our respects to their Elders past, present and emerging.

Jodi: Welcome to the MS Plus podcast. I'm delighted to be joined today by Mariam Metwally.

I do want to begin by clarifying that when we talk about women in this podcast, we mean people who are assigned female sex at birth. But we do acknowledge that not all women undergo women's health issues in a typical pattern, and not all people that identify as women will undergo women's health issues in a typical way, and not all people who undergo women's health issues will identify as women.

Mariam is an accredited practicing dietitian and certified fertility dietitian and founder of Tayyib Nutrition. She's passionate about helping women gain relief from women's health conditions like polycystic ovarian syndrome and supporting women and couples optimise their diet and lifestyle to support fertility and preconception health.

She's also passionate about MS and using diet and lifestyle to help improve quality of life, particularly for women in the preconception period. She knows the power of nutrition and lifestyle can absolutely shape not only a couple's chance of falling pregnant but being able to support the health of their future child.

She runs her virtual practice from Tayyib Nutrition where she supports clients one to one, as well as delivering a variety of support to educate and inform the community at large through webinars and her social media.

She recently featured in an ABC article talking about the impact of diet on polycystic ovarian syndrome and talked a lot about the value of the Mediterranean diet in the management of this particular women's health issue.

I am super excited to be joined by Mariam Metwally this morning who is a practicing dietician with a very special interest and passion for understanding the impact of nutrition and fertility and pregnancy and all things related to women's health and women's health issues really. Mariam, I'm just going to get straight into it. So, tell me a little bit about how this all started for you. How you sort of discovered this deep passion that you have for nutrition and the impact of nutrition?

Mariam: Yeah, sure. Well, thanks so much, firstly, for having me on Jodi. I'm super excited to be chatting all things women's health in today's podcast for Women's Health Week.

So, I guess, yeah, the long-winded story of how I got into nutrition in the first place. But I think in terms of how I got into women's health, I was midway through my degree, in my undergrad in the science degree component, we learned a little bit about what we call epigenetics or the basically the study of the Dutch Hunger Winter.

And this research basically showed that the impact of the diet of women who are pregnant and when they went through a famine and starvation, it had an impact not only on their children, for, you know in the short term, risk of preterm birth, but, we also, saw long term health consequences in terms of those women, who had malnutrition during pregnancy, in terms of seeing an increased risk in things like heart disease, diabetes, and obesity.

It was very interesting. And they also showed that, I guess, the different stages in pregnancy that were impacted by the famine impacted on, the health outcomes for the offspring. So, this led to, I guess, the whole development of research in that area, what we call DOHAD or developmental origins of health and disease, which basically has given us a lot to show that what women do during pregnancy in terms of the diet and the lifestyle and also the couple's health before they even fall pregnant can impact the child's health for the rest of their life and potentially even the grandchildren, so it can impact on the next generation as well, which is just mind boggling.

So that really, for me, was enough to show that, oh my god, this area is you know, really important. But then from there, when I guess I developed a bit more in this space and I figured how can I work in this space? I discovered the whole world of women's health dietetics and fertility nutrition. And that's where I thought, okay, that's a great intersection. So, if you work in the fertility space, you're working with women's health, you're automatically having this direct long-term impact in terms of the offspring's health. So, yeah, a bit of a long winded, story there.

Jodi: Way to go into it. That's really interesting that whole concept. Epigenetics is, it's difficult to get your head around epigenetics, well, I found so when I first started hearing about it. But I know that there's quite a few researchers in MS, who are looking at epigenetics and the impact of epigenetics, and I think it's such an emerging, part of our understanding of, the long-term impacts.

That's fascinating. I'd never heard of that research about the impact of women in famine who have those long-term outcomes. So, yeah, that sort of links me to MS and, women's health and MS issues. And that is also a particular interest for you.

Mariam: Yeah, absolutely. So, I guess, yeah, women's health and MS. So again, kind of, again, another deep little story here about how I got into this space as well. But I guess it was, you know, related to my own experience around being diagnosed with MS, kind of right after I finished uni. So, this is where I still had that passion for women's health, but I also was like really going deep into the research in terms of diet and MS.

And also looking at, okay, what about the impacts of things like MS on pregnancy and preconception health and things of this sort. But I, I guess linking it to epigenetics, like, one thing that like I think you mentioned is we know that diet, lifestyle and, you know, other factors can have a really big role in terms of epigenetics, which basically, the summary of what is epigenetics. It essentially means, we know that our genes don't change, the genome doesn't change, essentially. We don't expect to see a change between generation to generation, right? Over time, our genes stay the same.

But epigenetics is modifications that happen on top of the genome. So again, we have the same base genes, but then epigenetics impacts on which genes are actually expressed. so which genes are switched on and which are off. Now, when it comes to disease and MS, we know that that's really important. Like you mentioned here, obviously we know that MS or most conditions, there is some sort of genetic factor, but also there's that lifestyle trigger. So, it's obviously, as you would know, I'm sure with MS and other chronic conditions, researchers are super fascinated in terms of the impact of epigenetics, because we know that actually maybe we can modify the risk of people developing MS, if we are controlling the other kind of factors as well.

But I guess for women's health and MS, it's exactly right. So, I think like we're looking at the whole spectrum, right? So, I think one area that I've also found myself really interested in is women who are planning pregnancy with MS. Now this is again, I'm sure everyone who has MS and has considered having children or has had babies themselves would know that there's kind of a unique challenge in terms of, child rearing with MS because of all the different factors, which other people might not have to consider. So, maybe you're on disease modifying therapies, which pregnancy is actually contraindicated.

So that's where we say, okay, go back, speak to your neurologist and discuss what's our plan for preconception. But I, also think that this leads us to a really…it's a window of opportunity here because again, in my mind as a fertility dietician, I want every woman and every couple who are thinking of conceiving to make a start on their diet, lifestyle and supplementation to help impact or improve their things like their fertility, their pregnancy health, and then also the future health outcomes of their children.

So, I do think that, with MS, we can definitely use this opportunity of, okay, we already know that pregnancy, it is best to have that discussion, have that, really well planned with your healthcare team. So why not target nutrition in this time as well? Because we know that it can have such a huge outcome.

But I guess for women with MS who might be, I guess, anxious or worried about the impact of pregnancy, on their own health, on their own MS, or the risk of passing on MS to their children. It gives us, I guess an actionable item of something that you can do to be proactive, to really look after yourself as best as you can, and also best look after things like your pregnancy health and your future child’s health. So, I think it's, yeah, it's a no-brainer in my mind.

Jodi: Yeah, and it does give you a sense of control. I also found, as a clinician that when people were on the disease modifying therapies for MS, it created time frames around preparing for pregnancy which other women don't have. Like a sort of well, you really need to get pregnant within this set timeframe or there was even a perceived pressure of doing that and thinking as the months go by, and I found, and I don't know if this is your experience too, but I found that a lot of women then sought to get it, you know, didn't have that same sense of, “Oh, it can be whenever, I'll just wait and see.”

Mariam: Right, yeah, yeah, the timeframe.

Jodi: Has your experience being similar to that?

Mariam: well, I guess personally that's not something I've experienced yet in that I haven't tried to conceive. So, it's something that, it's a future kind of consideration of, of knowing and I guess when I discussed with my own neurologist about, you know, timeframes, you know, it's something that like, like you said, it really is dependent on each woman and their disease course and the medication and what their neurologist recommends.

But I do think, like I said, from what the research shows in terms of women with MS. Like, there's kind of, there's variabilities that there is like higher rates of women seeking support with things like IVF or other assisted reproductive therapies, which shows that potentially, you know, they, again, the evidence is not crystal clear here, but potentially some impact on fertility.

But I think you mentioned that pressure and the time frame. I think this to me shows that again, we have research to show that diet can reduce your time to conception. So, we know that in any couple who don't have any fertility struggles, there's an element of, you know, you can't fall pregnant every single month, right?

There's, there's a certain percentage, element that can fall pregnant each month. So, I think that timeframe definitely can increase that anxiety of, oh, okay, it’s just got to happen in the next month or two months or three months. But I do think, I guess, yeah. This is another reason which tells me, hey, another reason to really look into fertility nutrition, because we know that like, again, simple dietary changes.

So, depending on obviously what's going on for the person, you know, certain supplementation or diet strategies have been shown to reduce time to conception. So, for example, couples who eat fish twice a week for pregnant faster than those who don't. So really simple actionable changes here.

Same thing with here, like supplementation. So obviously your folic acid is is a default, but more things as well, which again, we know that women who take preconception supplement can reduce that time to conception. So, this is where I say, yeah, all the more reason to think about the diet and the lifestyle element even further if you know that there's a bit of a time crunch here.

Jodi: Yeah. Do you see a lot of women who come to you for that reason to say, you know, like I want to get pregnant quickly, how can I eat better to do that?

Mariam: Yeah, so definitely, I think when it comes to my fertility clients, unfortunately, I always think of, I wish we could buy time, but we can't, right?

So, people always say whether they're going through IVF or they're naturally conceiving. I mean, I think at this time of end of year where people will say, okay, I want to be pregnant by the end of year, or I want to be pregnant in January. And I, and I have to have a discussion of actually, you know, there's only so much that we can control, but some elements are not in our control at all.

So definitely, I think there's definitely the element of, especially for couples who've been struggling with infertility for a while, where the sooner they can fall pregnant, the better really. So, and that's why obviously we just try to do what we can. And obviously sometimes the diet and lifestyle is not going to be enough.

Sometimes we need extra support, whether that's through, you know, medical intervention, et cetera. But, yeah, like I said, diet and lifestyle definitely can play a role in terms of reducing that time to conception.

Jodi: Yep. And you talk about diet and lifestyle. What's the other lifestyle part?

Mariam: Yeah, sure. It sounds a bit of a buzzword, doesn't it? So essentially when I say lifestyle, I'm thinking about like the pillars of health. So, exercise is a no brainer. So, we know that, you know, trying to be active every day of the week, you know, part of our just general healthy activity guidelines. And especially for people with MS, that's extra important as well, because we know that for functional ability and reducing progression of MS, we know that the research on exercise is just phenomenal.

And this is where I'd kind of, shout out to my exercise physiologists and physio colleagues that their role here, it's just astounding really. But other things can include things like sleep, so making sure we're getting, you know, good quality sleep, restorative sleep, because that's where our body really recovers. And also, we know that there's a link between sleep and fertility. So, you know, the hormone melatonin can, you know, improve egg quality. And then other elements would be…

Jodi: I didn't know that one. I'm going to go back.

Mariam: Sure. Of course!

Jodi: So, and to talk about that, I think there are the sorts of things that are really like, we know that melatonin, I didn't know that. So, tell me a little bit more about the melatonin.

Mariam: Yeah, sure. So, I guess the research here has been done in women who are undergoing IVF. And generally, again, the research, we know that, again, shift workers are people who have poor, poor disturbed sleep, they can have more complications when it comes to infertility.

But from the top of my head, the study is looking at melatonin. So, they've basically done a randomized control trial. Think about how can we give women melatonin and then track the changes, and we've seen that melatonin supplements seem to improve egg quality.

So again, not a lot of the data around the fertility aspect. There's not heaps of it, but it's, it's definitely promising. So, when I think about melatonin supplementation, it's not just that every woman needs it. But to me, I draw the bigger picture. I say, you know, we know sleep's really important for fertility, so let's try to, and also our stress response, and all of those good things.

So, let's focus on that, but then for the women who do have an extra concern around egg quality. So, I'm thinking here women who say, are above 35 or so because that's when we know egg quality does decline over time, unfortunately. And I guess linking it to MS as well, women who have, I guess, more advanced disease activity or more, uh, progressed MS, we know that there is higher levels of circulating inflammatory cytokines, right?

So, inflammation we know is not very good for egg quality. So, this is telling me that, you know, if someone has more progressed or advanced MS. Then maybe I personally, as a clinician would be extra focused on the egg quality. And that's where potentially there may be a lot of supplements, but I always say supplementation, especially melatonin, get that tailored to you.

So even in Australia, like melatonin, you're meant to see your GP or a doctor for a script is unlike in the States. You can just pick it up off the counter because we know that we're playing really closely with our biology here. So yeah, when it comes to supplementation and medication, obviously a discussion to be had with your healthcare professional.

But sleep, I think most people, myself included, and a lot of my clients would definitely benefit by improving their sleep quality and also just duration. So, most of us are getting sleep a little bit too late.

Jodi: Yep. Yep. And I think in that whole lifestyle framework, one begets the other you know …

Mariam: oh, a 100%

Jodi: a better diet, better exercise begets a better diet begets a better sleep. So, they all actually, I often used to say to someone, you can just pick one because you'll find that over time one begets the other, you know, and you don't have to do it all at once, but eventually over time. That was certainly, that one, one improved the other. Uh, and, and you got good sleep when you were exercising better, and you were eating better and...

Mariam: Yeah. Completely agree there. And like, again, as a dietitian, I generally work with diet first because that's my profession, but in saying that, I'm always also tapping into, okay, within my scope, obviously, is okay let's look at diet and, sorry, let's look at exercise and let's look at sleep because these things, like I said, it feeds into each other.

So, if we're sleeping poorly, research shows that people who have poor quality sleep or reduced duration of sleep, their insulin sensitivity is reduced the next day. And they're more likely to crave and reach for high sugar, high fat foods. So direct link here between poor sleep and then making poorer dietary options because you're just too tired and your body's looking for quick energy.

Jodi: Yeah, yeah. So, moving on from pregnancy and egg quality is something you must talk a lot about. It's not in my everyday conversation, but what about the rest of the hormone picture? Like, how do you approach it when you are talking to someone about it, where they have hormone fluctuations, right? From getting irregular periods to menopause. Like, how do you see the role of nutrition there? And what can women do about it?

Mariam: Sure. Okay. Very, yeah, I guess a really broad question. And this way, yeah, big question. I guess the first thing I think of when you mentioned nutrition and hormones, my brain goes a lot to my clients who have conditions such as PCOS or insulin resistance, because these are conditions that the diet directly is linked to our hormones here in a very tangible fashion. So, for example, we know that if we have some level of insulin resistance, we know that, you know, the amount of carbohydrates we're having and other kinds of diet quality is going to impact that level of insulin resistance, which is a hormone essentially, right.

And then PCOS as well, we know that, for example, women who have really long menstrual cycles, we've got some really great research here, or some good stats that, you know, literally five dietary changes can, improve ovulatory fertility by 69%. And when I say ovulatory fertility, I think about even if people are not trying to conceive per se, if you have a very irregular cycle, very long cycle, that's telling me that you're probably not ovulating.

So regardless of the, that desire to conceive or wanting to have a baby, then the diet can play a really key role here in terms of having a regular menstrual cycle as well. And then I guess there's other things again, looking at other, you know, factors. So, I guess other things I think of here as well is, things like PMS or even period pain.

We know that diet can play a role here as well. So again, a lot of it here comes back to reducing that total, I guess, inflammatory load in our diet. And because we know the prostaglandins there, that's what tends to cause period pain and those, and those uncomfortable symptoms. So, we know that if we're focusing on more, a low inflammatory diet, that's going to help dampen down the inflammatory response, which can help improve things like period pain.

And then when it comes to even things like PMS, we've got, you know, it's not a complete picture here, but you know, just your own dietary strategy. So, you know, just your general healthy eating, plenty of fruits and veggies, choosing more whole grains than your refined carbohydrates, reducing our saturated fats as well.

Obviously with, you know, not smoking, not having excess alcohol, that can all improve PMS as well. And then there's also a role to be had for extra supplementation as well here. So, for example, things like calcium, vitamin D, magnesium can also tend to play a role. I guess, like I said, very broad question and I'm just tapping into different topics here, but when you mentioned menopause, one thing I'm thinking of is, yeah, obviously uncomfortable hot flush symptoms then, but also like bone health.

So, we know that menopause for women has a direct impact on their health, so increased risk of heart disease or heart conditions, poor bone health, osteoporosis, osteopenia. So, in women who are in that pre- or post-menopausal stage, we're really focused on how can we use the diet to help support their long-term health and reduce that, those risks.

So, you know, trying to have a really heart healthy diet, trying to support bone health. And this is where dietary wise, we're looking at calcium, we're looking at vitamin D, Also, you know, not having excess amounts of things like your caffeine, your salt, and then lifestyle. Exercise, we know that, you know, strength, you know, weight bearing activity is very important for protecting our bone health and preserving that strength. So, yeah, I'm not sure that answers your question here, but that's where the...

Jodi: No, we're on the right track. I think you talked a lot about the impact of inflammatory prostaglandins and the whole inflammatory picture. When you were talking about that, I was thinking about how overwhelming diet information is.

When you think there's so many different ones, there's so many different thoughts that, how much do you find all the information, all the different things that you can do, like you go on Instagram and there's like so many ways and so many things and so many recommendations, how much in your experience is that a barrier to people doing things? And how do you kind of help people through the journey of it being... to me, it feels really unrealistic in making that stuff. How do you tackle that?

Mariam: yeah, oh absolutely. Like I'm completely with you here that, people think again, if you're just diagnosed with a chronic condition, whether it's MS, it's PCOS, it's, you know, you're struggling with infertility. As we want to look for answers and we want to be in control. So that's where, you know, the Googling, the Instagram searches for diet recommendations, and eventually just what I see with my own clients, but also in my, in my own experience as well, is the more you do that, you just get overwhelmed.

And as human beings, when we’re overwhelmed, we just don't make changes. So, you might think, okay, I'm going to cut out, I don't know, depending on whatever condition, I'm going to cut out dairy and gluten, and I'm going to cut out meat products and all of these products eventually can, maybe we can sustain that really restrictive approach for say a week or two weeks.

And then it becomes really hard. You have a wedding that comes up, you have a party, and you just think, okay, I'm going to give up. This is just too hard. And then perhaps we actually haven't progressed at all in the long term, we're going back to the same dietary pattern as before and potentially even a little bit worse as well.

So, the way I tackle it with my clients is. Firstly, a lot of empathy, like I can completely understand why you felt the need to go down this pathway and this rabbit hole. And, and then also a bit of, again, the empathy in terms of, okay, look, I appreciate that you want to be trying these approaches. I just think where the research is at, that this, and also your picture, this probably is not the best approach for you.

So, a bit of education as well and discussing what I think will be the better change to be focusing on, the better changes. And also, behaviour change is hard. So, as a clinician, my approach is not to say, okay, I'm going to give you a strict meal plan to follow and we're going to make all the diet changes at once.

I'd much rather, and what the research supports as well, from a behaviour change perspective, is changes that we build over time and it becomes habit that can be sustained for a lot longer rather than doing a short, you know, challenge, or a short diet stint, which again, longevity wise, it's not going to, it's not going to last.

And when I think about chronic conditions like MS and other women's health conditions, PCOS, endo, they think about their lifelong conditions. So, the diet that we're having needs to translate for life. And the way I see it is if we're just making changes that are only going to last in the short term. It's probably not going to have much benefit if we're thinking about the management of a chronic condition.

So, we want changes that can be sustained for the rest of our life as best as possible. And I always say the things that we can just, we can always improve, we can always build, and whether if it's not the diet, it's the exercise, if it's not the exercise, it's the sleep, which as you mentioned, it's a whole circle here, right?

So, I think, you know, just to maybe a word of advice for people who are going down this wormhole of the rabbit hole is sometimes, you know, more is not more. If you're feeling overwhelmed, maybe just take a step back. And I always would say, if you are finding that you're really struggling and you're overwhelmed, then reaching out to for personalized support by, you know, a dietician, or, you know, other health healthcare professionals, if it's different areas like exercise, I would always recommend that because it cuts through that confusion.

And always again, you go towards reputable sources if you're doing your research because, you know, Instagram, TikTok even, not very reputable. I mean, yes, there are better, obviously there's a lot of dieticians on Instagram that I follow a bunch of them as well, which put out fantastic research, but, again, it can be really hard to tease out what is, you know, good, evidence based and high-quality recommendations versus things that are maybe just based on personal experience.

Jodi: Yeah, yeah, I often reflected that with starting exercises is similar, you know, making sure that you plan that the people around you are going to have your back, you know, in terms of making those changes and, you know, a personal trainer might be an investment for three months, physio, exercise physiologist, you know, three months, but a dietitian as well, they'll keep you accountable, which is very happy. But also, you know, keep you accountable, but it's part of that whole concept of this team doesn't have to be forever, but this team for now will help me get on track to create those sort of little changes over time.

Mariam: Absolutely. Absolutely. I'm completely with you, especially with exercise, especially if you've never, for example, like, uh, exercise is just so important and whether that's for MS or other women's health conditions. And you know, I think often I'm encouraging my clients to, you know, pick up maybe some resistance training because the evidence around that is just so phenomenal.

And this is why I say, look, if you've never been to a gym or you've never done strength training, then, you know, I don't expect you to go and figure out on your own. And that's where, like you said, going that is short term investment in terms of using an exercise physiologist, a PT, a physio, and then you know how to do it yourself, you can do it on your own, that gives you that that self-capacity.

Really and same thing with diet like, I would say my goal is that I'm not with you long term. Yes, in the short term while you're making changes, I'm here to support you and hold you accountable and things of this sort, but over time you should develop the skills to not need me in the long term as well.

Jodi: Yeah, yeah, I think we often think of personal trainers, you know in the exercise space, but not that same…dietitian seems to be much bigger, you know, or there's that sense of, I can do that on my own because there's all these different books and all that sort of stuff, rather than saying, actually, the reason I'm going to see a dietician is not necessarily because I don't know the answers, it's because I know that I need to have someone help me get into these patterns, to make a long term sustainable change. So, you know, dietitian as the personal trainer for food changes is a really good way of thinking about it. To say, I'm not coming to the dietician because I don't, know about it.

You don't go to an exercise physiologist necessarily because you don't know about it. You go because you want someone to help you along the way to make those changes. So important to do that, and we didn't really talk about, in all areas of your life and in all times of your life. I think, like you said, everyone wants the answers, but I actually think lots of people, when I talk to them, know the answers.

It's just how you get there. And then there's all the little tips that you get on the side, you know, like magnesium might be useful here or, vitamin D might be useful there.

And, for instance, thinking about vitamin D and diet and all the different advices in MS, it is something that I think a lot of people find really challenging, just the amount of information and contention about how much vitamin D should I actually be taking? Should I take vitamin D at all?

You know, should I never eat meat again? You know, gut biome seems to me like, important, but somehow just enormous. What's your recommendations around, we'll start with vitamin D? Around all of that, navigating all of that information that's so hard to navigate.

Mariam: Well, I think firstly around vitamin D, like actually, I think we've got now some conflicting data. We used to have some research, we know that there's a direct linkage between vitamin D deficiency and risk of MS, which like, again, we know that rates of MS is a lot higher the further we are away from the equator, so Tasmania has the highest rates of MS in Australia.

So, we know vitamin D and sunshine does play a role. But then like I said, we've got kind of new research which shows that potentially supplementation is not beneficial. Look, the advice I take here is... Speak to your healthcare professional around what their recommendation is for you, because, you know, I'll just speak personally, you know, my neurologist, she's like, let's get your vitamin D at a good level.

And I think, look, the way I think about it, most people can benefit from improving their vitamin D status because even if it's not MS related, like it's important for mood, it's important for, fertility and hormones and egg quality and things, all of these types of things. So, I think most people, in my experience, their vitamin D is quite low.

So, I think if you're deficient or if you're kind of in that low range, then definitely get on top of it. In terms of specific advice around supplementation, always chat to your healthcare professionals around here, whether that's your GP, your neurologist, or a dietitian, to have it tailored to you because there's no one size fits all, here as well.

And then in terms of navigating diets for MS, so yeah, completely empathise here that it, it is overwhelming. And like you said, they're conflicting. So, one of them will say, do this, and the other says, do the complete opposite. Look, the view that I, I take really is, again, I think my response coming back to what I said earlier, that the best diet for you is going to be what you can sustain for the long term.

So, for some people, maybe one of the more extreme protocols for MS. I'm thinking like a paleo style, for example. If that's something that you think you can sustain for life, then you know, like by all means. I think for the most part it's a lot of the approaches, the more restrictive they are, they more they are challenging and most people, again, they're not able to maintain it long term.

The view I take is really, let's bring it back to the, and there isn't like strong guidelines or evidence around diet and MS. So, I think the viewpoint I like to take is, let's focus on a general, healthy, balanced diet and I also knowing that MS is an inflammatory condition and I've spoken, we've touched base a bit on this before, the approach that I like to take as well is really trying to, you know, have that more Mediterranean style or more low inflammatory approach.

So, can we get in more omega 3s? Most people probably can, and especially with MS and brain health, we know that omega 3s are really important. So, trying to dial in those, those extra kind of good fats, reducing the bad fats. So, you know, your saturated fats in our butter, our meat, the fats on meat, and potentially even full fat dairy, then they're things that ee want to scale back.

So, it's again, looking at themes and big, broader stroke changes. When it comes to our grains, you know, switching from the more refined processed carbohydrates to a more slow release, low GI whole grain carbohydrates, which tends to be a lot better for overall health, but also our heart health and brain health, which again, we know there's a direct linkage here between reducing a risk of, you know, comorbidities like heart conditions and, high blood pressure and our progression with MS as well.

Probably the biggest I'd start it, and I mean, I'm always going to harp on about fruits and veggies, right. But definitely trying to get as much as we can of these good, you know, fruits and veggies, it's like it tackles so many different benefits. We get all the color, the antioxidants, which helps to reduce inflammation.

We get the fiber, which supports our gut bacteria as well. And with, just on the point of the microbiome, I always say the more plant variety we can get per week, the better our gut microbiome will be. So, we've got research to show that, you know, having at least 30 different plants per week, can improve the diversity in our gut microbiome.

Now, gut microbiome, like I said, it's a fairly new area, but we do know diversity seems to be linked with better gut health on the whole. But given that linkage within, again, the microbiome and MS, again, the fiber, the color, the different plant varieties really important. On this point as well around the gut microbiome, our beans and legumes, so there's plant proteins and nuts and seeds, again, are really beneficial.

So, they not only help to reduce inflammation, reduce cholesterol and things of that sort, but also support the gut microbiome. And then I think around other proteins, like your red meat, your poultry, your eggs, again, there's going to be different approaches here as well, but the view I like to take again is potentially, you know, having, I think in Australia, most of us have red meat pretty often, so maybe having it more as a, shifting our proteins so we're getting a bit more balance. So maybe trying to increase it again, the fish and seafood, the plant proteins. That maybe having red meat a couple of times per week rather than every day.

Jodi: Yeah. And I think, you know, I was speaking to some women yesterday and they're saying, I never know whether this is menopause symptoms or MS symptoms or any other symptoms, but what I'm hearing from you through all of the areas that we've flown through, PMS, healthy eggs, all those things, that key theme of that anti-inflammatory approach and the impact that diet can have in overall inflammation and sometimes you can't work out which is which. This is one thing that you can do for both, is what I'm hearing.

Mariam: Yeah, yeah, look, definitely, I think as a dietitian, I'm always, again, the Mediterranean diet is just, it's just got so much evidence for so many of these various areas.

So now I'm speaking to a client, I'm like, “oh yeah, you probably already know this, but Mediterranean diet is great for fertility, it's great for PCOS, it's great for endometriosis, MS.” Definitely.

Jodi: Yep. Yeah. Yep. And like you said, it's about the principles related to the Mediterranean diet and I've had many neurologists sort of support that concept as well too, about having the Mediterranean diet and being able to do that and, the influence that anti-inflammatory diet can have in all areas of your life. And that's particularly important for women with MS as well. Well, thank you we've flown through so much today and there's so much more that I would love to learn about, particularly about pregnancy planning, I think a lot of women are so keyed into now the emerging research in epigenetics and the impact of that, that early time. Is there anything that you kind of think, you know, if you could tell every woman with MS, or every woman actually in regards to women's health, what would be your sort of key things that you would love to get the message out there?

Mariam: Okay. Firstly, I'm going to say, again, I've probably, this has been the key thing that's come through, but focus on the fundamentals is always my key picture. I think the number one piece of advice, which I think every Australian, every woman can focus on is, eat more fruits and vegetables every single day. Get as much colour as you can on your plate.

Number two is move a little bit or, you know, move as much as you can every day. So, for some people, if, you know, the gym is not your thing, maybe go out for a walk. But I think that, again, maintains the activity levels. It's so supportive for us, whether, regardless of goals whether it's, you know, fertility, PCOS, MS, or even menopause, we know that most again most Australians are not meeting our exercise guidelines. So just do what you can, do what you enjoy, and then,

And then my final piece of advice is going to be... Whether it's diet, whether it's exercise, or stress management, so your mental health, if you're struggling, I always just encourage you to reach out for support from someone who's trained in this space, really, so whether it's a dietician, an exercise physiologist, or a psychologist, because it just cuts through all the confusion and overwhelm of trying to do it yourself. And sometimes like, again, like you spent years doing one approach and you realise it's not the right approach. So going straight to professional can just cut through a lot of that overwhelm and confusion.

Also, if I can give a final plug or maybe here is, yeah, I think when it comes to preconception and fertility, the role of diet and supplementation and again, that lifestyle is just can't be overstated. So, I would always say if every, you know, would, I would love for every woman who was thinking of conceiving or wanting to conceive to reach out to a dietitian who works in the fertility space to just make those correct changes in supplementation to support your fertility and preconception health.

Jodi: Yeah, it's so important, so important and becoming more and more. So, thank you. I'm gonna go home and go back to my good commitment. I'm inspired to go back to my commitment to Mediterranean diet. I think like most people, I do fluctuate with having very good years and then not so good years, but that's okay too. That's okay too.

Mariam: Yeah, and it's always a journey with lifestyle and diet. Again, I always tell my clients, I'm a dietician. I don't have it a hundred percent all the time. I really don't. I'm still human. None of us have it a hundred percent of the time.

Jodi: But thank you for your time today. And we look forward to, hopefully we'll get to chat more.

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