Welcome to today’s episode. Whether you have MS, MOGAD (myelin oligodendrocyte glycoprotein antibody-associated disease), or NMOSD (neuromyelitis optica spectrum disorder), I’m excited to share some fascinating insights into the gut microbiome with you today. My guest today is Dr. Natalia Szejko, a dedicated neurologist and researcher specializing in these disorders. Dr. Szejko’s work focuses not only on better treatments but also on exploring innovative areas such as the role of the gut microbiome in disease progression.
In our conversation today, we will explore the latest research and discuss how lifestyle changes such as diet can potentially impact our health. As someone who has first-hand experience with the challenges of these conditions, I am excited to offer you practical insights that can make a real difference in the treatment of MS, MOGAD, and NMOSD. So, stay tuned – there is a lot to be hopeful about!
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Table of Contents
Introduction – Who is Dr. Natalia Szejko?
My name is Natalia and um I’m a neurologist trained neurologist and I’ve done my studies and later my specialty in adult neurology in Poland and also I did my PhD there and during my training I had an opportunity to work with patients with MS and related disorders and it was like a year-long experience with a great team of researchers and clinicians who really taught me a lot about this disease and it was very inspiring.
Now I’m completing a clinical and research fellowship in Calgary in Canada. And I’m a member of European Charcot Foundation. We have like a junior membership where we are fellows and I’m trying to be very active. I’m a member of the steering committee and also a member of TSF, The Sumaira Foundation, which is related to NMOSD and I’m the ambassador for Poland.
In terms of my research and clinical interests, they are related to, for example, treatment of MS with alternative and complementary medicine, one of them is the gut microbiome. And now I have also conducted clinical trials on MS and related disorders.
Personal motivation for your career choice?
I think that this field gives a lot of opportunities to help the patients. It’s very inspiring because it’s developing very quickly. I think it’s one of the most developing fields in neurology.
The stories of these patients are also very inspiring and I had also great mentors and clinicians so I think it’s extremely important to have people who inspire you which are mainly the patients. And I think for the clinician the motive is most important that you have a good relationship with your patient.
Understanding the Gut Microbiome and Its Role in MS
What is currently known about the role of the gut microbiome in the pathogenesis of multiple sclerosis and related disorders?
It’s a very complex Topic. Last year with my colleagues from Poland and Austria, we wrote an article about it trying to tackle the most important topics. So it’s been discussed for years and as you heard probably also not only in MS generally in different neurological disorders because now it sort of became like a hot topic this gut-brain axis which is true it exists. We know that basically there is a very strong interaction between the gut microbiome that can impact the brain health on different levels. It was like an inspiration for overall investigation of this topic.
There are so many different levels. One level, it’s been discovered, in the most investigated animal model, which is experimental autoimmune Encephalomyelitis (EAE).
And it’s been already demonstrated on animal models that there is this interaction in a mass. And later, the this was transposed to research in humans. And we know that, there is like a two-way interaction. So basically, the patients with MS, they have specific changes in gut microbiome. And this could be related both, changes in this gut-brain axis, but also now it’s postulated that it could be some changes in the gut, they can also influence the immune system. And as you know, immune system is very crucial in a mess. So this is on another level, that’s probably both the brain itself is influenced, but also the immune system. And coming back to sort of or or circulating to to what we can do in humans and and the clinical work is that eventually also some clinical applications and treatment applications were related to heartbreak gut microbiome. As you heard probably, the use of different diets, right? Because we know that diets, they have very strong impact on gut microbiome and whether this indirectly can impact the gut and then help people with MS in their symptoms.
On the other hand, they use of probiotics, which is also a long-hanging fruit, a target that we could use to modify the disease or even treat symptoms. And finally, a hot topic overall, I would say, not only in MS, but in other disorders is a fecal transplantation. So we can transplant from healthy individuals the gut microbiome.
So all these different levels from part of physiology on different levels. So to very briefly summarize. The impact on the brain, the impact on the immune system. And then sort of whether this have also impact on progression of disease. Finally, application in clinical trials.
Do we know if changes in the gut microbiome occur before the onset of MS or other related disorders, or do they develop as a result of the disease?
I think it’s much easier currently, to do a study in which we just compare sort of patients with MS, their gut microbiome with healthy controls.
So basically this kind of studies, it’s like where it’s been done and it’s like low-hanging fruit. And basically demonstrated that a variety of different taxa of bacteria are different, so are more prevalent or less prevalent in MS. And one of them is, is for example, related to short chain fatty acids, this kind of bacteria that process this kind of substances.
And this is easier to do, and we have a variety of these studies. But there are very few studies that investigated so far whether this could be a trigger for development of MS so that people who are healthy, they have a different diet or some predisposition that can eventually lead to development of MS because of the changes in gut microbiome.
So this is still ongoing investigation. And we don’t know so far, but I presume that, it could be one of the factors, but it has to be confirmed. Yes.
The Interaction Between Diet, Gut Microbiome, and MS
How much can the gut microbiome be influenced by a healthy diet and overall lifestyle, and what impact could this have on the severity or progression of MS?
We know that every person has like individual microbiome. So it’s like a very personalized sort of Intervention. Probably you heard about personalized medicine so it’s great for this target too. So this is nice but also complicated because every person is different but basically the reason why it’s different is first genetics. We know that genetic predisposition has an impact on gut microbiome but then Second, as you said, environmental factors. One of the main ones, we know it’s the diet. So, if you eat a lot of fatty things, the bacteria that love these fatty things, they will develop.
And on the contrary, the ones who are more developed in vegetable-based diet, they won’t. So it’s very logical. This has a huge impact. and And what I can definitely say, and this is another hot topic in MS now, and I think it’s very promising and interesting. And again, an easy target. So the diet, so many trials have been tried and and you you know for different diets. Ah Ketogenic diet, no fasting diet, very different intervention. But what we know exactly, I was in the Congress of American Academy of Neurology this year, and there was a great talk, a hot topic.
So basically, the only diet that we know has a positive impact overall all on the disease on the mass is the Mediterranean diet. So basically plant based with a lot of fish and a reduction of processed food. So this definitely overall has good impact on the mass.
But also has an impact on gut microbiome and this would be the only sure recommendation that I have for our patients now which you probably already knew. I’m just confirming the fact and this is from the trials um what we know and the one that we would strongly recommend. So not really otherwise, you know because like I said, there were trials with, for example, also gluten free diet. For now, we don’t know, there is no data to give us confirmation that it’s working, but the Mediterranean one, yes, please follow this one.
Gut Microbiome as a Therapeutic Target
How realistic is it to use the gut microbiome as a therapeutic target in MS?
I think it is realistic because we have a lot of potential interventions that are not as invasive as others. For example, this could be the diet. Again, this could be a probiotic that the patient takes. Fecal transplantation, of course, it’s a little bit more invasive, but still it’s not like a transplantation of hemopoietic cells, right? So less invasive. And like I said, we are moving towards the personalized treatment. So I think, again, this could be a very nice sort of niche where we can combine this. But the problem is that it’s very complex.
We do not really influence one taxa, we influence the whole microbiome. So that’s the problem at the moment. So again, the only diet that is working is this Mediterranean at least from the data. And it’s not only because of gut microbiome.
Generally, we know that it’s healthy and it impacts the immune system too. So what we call low grade inflammation, it’s stopped and definitely this helps in MS and overall, so on different levels.
So far, unfortunately, we don’t have very strong data that support the use of probiotics. Again, this is indirectly, we’re thinking that, maybe this has an impact on gut microbiome. And this was why this will help people with MS. So far, we don’t have very strong data to support this.
And fecal transplantation, so far it’s limited to very small trials. The evidence of the data is not very strong. It’s an investigating debate. I think definitely the diet and and the probiotics is the intervention, and that is realistic.
The problem from my perspective when I was reading the trials is that it’s very complex. So if we discover like so far we know is the change of the composition of gut microbiome in people with MS- But if we discover how to simplify it, then it would be easier. This is the only problem that we have right now. I think it’s realistic.
Plus, the intervention could be easy. We have to simplify it because, it’s a huge amount of millions, trillions of different bacterias that we have impact on.
And apart from this, there is an impact on immune system and very complex interaction between central nervous system and even peripheral because now there are very nice studies showing that also gut microbiome has impact on the small neurons that are for example located in our gut. There is more production of Serotonin. So if we find one specific target and one pathway. I think it we should start from there because otherwise you know you’re impacting everything and we are not sure what is working and that’s why maybe we are failing so far. But I’m very hopeful because it’s an easy intervention.
What would a potential gut microbiome-based therapy for MS look like? Would it involve one-time interventions or require ongoing treatment? And how would such a therapy be delivered?
Logically, I think it would require more long-term therapy, especially with probiotics. Obviously, it’s not enough to take probiotics just once; it has to be a repeated intervention. As for fecal transplantation, this could potentially be a one-time intervention.
However, as I mentioned, the trials so far have been small. In animal models, it’s been shown to work, and the sample sizes were larger. But in humans, we haven’t had much success yet, mainly because the sample sizes have been too small to demonstrate statistical significance.
So, depending on the intervention, you’ll determine how long it will last. Probiotics would likely require long-term use, while fecal transplantation might only need to be done once.
Diagnostic and Predictive Potential
Could the composition of the gut microbiome help determine the subtype of MS in a patient and help make individualized treatment decisions?
As I mentioned, the majority of studies, unfortunately, focus on patients who have already developed the disease. And, of course, it’s a complex condition. You’re absolutely right that we are now trying to dive deeper into phenotyping, beyond the classical divisions like relapsing-remitting, primary progressive, and secondary progressive MS. We’re now looking at even more specific features, including genetic ones.
Most studies have been done on people already diagnosed with MS and classified by these classical subtypes. However, one doesn’t exclude the other — a patient with relapsing-remitting MS can later develop secondary progressive MS. So, further investigation is needed.
So far, we’re lacking long-term prospective studies that track the gut microbiome at different stages, such as at diagnosis and over time, to see how it impacts MS progression. Only two studies have done this so far, showing some changes and potential biomarkers for subtypes, but the sample sizes are too small to draw firm conclusions.
This kind of research is crucial because it could provide a valuable biomarker, helping clinicians predict disease progression. It’s also an easier material to collect compared to blood. So yes, I think it would be great, but with just two studies, it’s still too early to conclude much.
Are there any biomarkers within the gut microbiome that could predict the course or severity of MS?
Dr. Natalia Szejko: Yes, yes, yes, yes.
Nele von Horsten: Okay, that’s interesting. And of course, I think this field is just starting to grow. Maybe at some point, it might really take off. We’ll see, but it’s a very interesting direction.
Dr. Natalia Szejko: Yes, yes.
Future Directions and Research
What are the next steps needed in research to better understand the connection between the gut microbiome and MS?
Dr. Natalia Szejko: So, I think there are several key steps. First, as I mentioned, we need more targeted interventions. Rather than casting a wide net, we should focus on specific taxa that are either overrepresented or underrepresented in MS. By targeting just one, we can better understand why something works or doesn’t work.
Second, as we discussed, there’s a real need for long-term, prospective studies. We should be comparing healthy individuals to those who will develop MS, examining how initial gut microbiome changes might influence the onset of MS or related diseases like NMOSD or MOGAD. Similarly, in MS patients, long-term studies could help us understand disease progression better. We’re searching for disease modifiers, and something as simple as a probiotic, which targets just one bacteria, could potentially help. For instance, preventing a patient with relapsing-remitting MS from progressing to secondary progressive MS, which is harder to treat, would be a significant step forward.
Another important aspect is the need for larger sample sizes. International collaboration could be key here. Bringing together different countries and initiatives, such as the European Charcot Foundation, can help increase the number of patients enrolled in studies and ensure diverse populations are included. Gut microbiomes are highly individualized, influenced by genetics, ethnicity, and diet. For example, comparing populations from Poland and Japan would reveal differences due to diet, geography, and genetic background. This means findings in one population might not apply to another, so cross-comparisons are essential.
Take the U.S. as an example, where a significant portion of the population consumes processed foods. It would be fascinating to compare these dietary habits with other geographical regions. I believe that by confirming these differences, clinicians could tailor interventions more effectively. A doctor in Japan might need a different probiotic than one in Poland, based on the unique needs of their patients.
International collaboration is critical, and I’m very much in favor of involving patients in research. It’s important to ask patients what interventions they find tolerable and suitable. I’m glad to see this is growing, as it’s essential from an ethical perspective to give patients with MS a voice in research. For too long, they were silent, lacking the opportunity to express their needs.
These are the future steps we need to consider. I’m hopeful, as you said, that this field is developing quickly, and I believe we’re just at the beginning.
Nele von Horsten: Ah yes, I was just thinking about Lisa-Ann Gerdes’s group and their MS twin cohort. It’s interesting because in these cases, one twin may not yet have MS or a related disorder and hopefully will stay healthy forever, so you can study their gut microbiome, MRI, and other factors to get insights. Of course, the sample size isn’t large since we’re talking about monozygotic twins, but it could provide an initial direction, right? Hopefully, there are other twin cohorts around the world that could help boost the numbers and contribute to similar studies.
Dr. Natalia Szejko: Yes, yes, I think so. And in addition to this, we now have a lot more opportunities due to the democratization of research. The idea is to create open resources for different researchers. Of course, the data is anonymized, and there are criteria to meet for access, but you’ve probably heard of initiatives like the UK Biobank or the „All of Us“ cohort in the U.S.
These cohorts are great resources. For example, „All of Us“ covers all age groups, which is ideal for MS research because it includes young people and healthy older individuals who are being studied longitudinally. This allows for cross-sectional comparisons between healthy individuals and those who might develop MS. The UK Biobank, while focusing on an older population (around 50+), still provides access to their diagnoses, which can be extremely valuable for research.
We’re actually considering working on the UK Biobank cohort with my colleague Sarah, who I think you know well. I’d encourage other researchers to explore these publicly available cohorts as well—they offer a wealth of data and opportunities for collaboration.
How soon do you think the insights from gut microbiome research could be translated into practical therapies or diagnostics for MS patients?
Dr. Natalia Szejko: Yeah, I think, as I mentioned, there are more and more studies, but we’re still in the early stages. I’m hopeful that in the coming years—maybe within a decade, though that’s just speculation—we’ll have more solid findings. But, as I said, we need larger sample sizes to confirm these ideas we’ve been discussing. Still, I’m optimistic that within the next decade, we’ll have something more concrete.
Nele von Horsten: Yeah, I agree. It’s important to have a realistic perspective. While 10 years might not seem like much time in the grand scheme, it’s still a lot when you consider how much research needs to be done. Many patients hope for breakthroughs in the next year or two, but unfortunately, that’s not always realistic given the complexity of the work involved.
Dr. Natalia Szejko: Exactly, exactly. In the meantime, you can always encourage patients to follow a Mediterranean diet—there’s no harm in that, only potential benefits. While the science is still a bit vague at the moment, it’s definitely a promising field. What we do know for sure is that a processed or fatty diet won’t help your microbiome or your MS. So, that’s something actionable you can do right now.
Quickfire Q&A Session
Complete the sentence: "For me, multiple sclerosis is...."
Yes, they often face many struggles in life, but still manage to overcome them. It’s also a fascinating area of research, though secondary to the main focus. But yes, it’s definitely an interesting field as well.
What development would you like to see in the field of multiple sclerosis in the next 5 years?
Yes, I’m really looking forward to the future, as we’ve mentioned. I’m glad to be in this field because there are so many new possibilities we can offer to patients. However, I still feel that for those with primary progressive or secondary progressive forms of MS, we’re not doing enough yet. While we do have some treatments, it would be great to see more options to help these patients. That’s one key area I hope to see progress in.
Another area is related to MS but focuses on NMOSD and MOGAD, which are often underrepresented in research. In my experience, especially in Poland, even patient associations for these conditions are quite small, and those with MOGAD, in particular, often feel excluded. While NMOSD now has some disease-modifying treatments, MOGAD, with its distinct and more acute pathophysiology, still lacks specific interventions. It would be great to see advancements there as well.
So, for these two—actually, three—populations of patients, I’m hopeful that more is coming down the pipeline. And I’m confident there will be, as we’re fortunate to have so many possibilities ahead. So, yes, stay hopeful.
Farewell
Finally, what message of hope or encouragement would you like to share with the listeners?
First of all, I think it’s important to recognize that the field is developing very quickly. There are so many investigators and companies investing in this area, so don’t lose hope—even for those with more challenging forms of the disease, like primary progressive MS, that may not be responding well to current treatments. I believe we will have more treatment options soon.
Another piece of advice is to join forces with other patients. There are many inspiring stories and organizations that can offer support. Getting involved can make a real difference. I’ve seen firsthand how supportive groups, not just for patients but also for caregivers, can be incredibly beneficial. Hearing these stories and sharing experiences can really help.
Finally, I’m hopeful that patients will be more involved in research going forward. Your input is crucial—what you think makes a good intervention, what you’d like to see investigated. This is a message of hope: I hope you no longer feel excluded from the process.
Overall, I believe there is real reason for optimism.
How and where can interested people follow your research activities?
You can find some of my studies on PubMed, and I’m also listed on the European Charcot Foundation website under the steering committee, where updates will be published. We’ve been quite active, and with Sarah, we’ve created a LinkedIn page for the European Charcot Foundation, where we’ll share more updates and information.
Additionally, you can follow my work during conferences where I’ll present my research. I was really happy to be here today!
Thank you, Dr. Natalia Szejko, for your incredible dedication to advancing research in MS, MOGAD, and NMOSD. Your work brings hope to so many of us living with these conditions, and we’re truly grateful for your passion and commitment to improving patient care and outcomes.
See you soon and try to make the best out of your life,
Nele
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