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Alhaj OA, Trabelsi K, Younes AM, Shivappa N, Bragazzi NL, Hebert JR, Jahrami HA. Diet-related inflammation increases the odds of multiple sclerosis: Results from a large population-based prevalent case-control study in Jordan. Front Nutr 2023; 10:1098883. [PMID: 37090771 PMCID: PMC10113660 DOI: 10.3389/fnut.2023.1098883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
Background Multiple sclerosis, a chronic inflammatory disease in young and middle-aged adults, is one of the leading causes of non-traumatic disability in adults. Diet is known to have an important role in the modulating inflammatory processes and influencing molecular pathways. Purpose This study aims to examine the association of the inflammatory capacity of diet measured by DII with MS in Jordan. Methods This prevalent case-control study included participants of both sexes, aged between 20 and 60 years. The cases (n = 541) had a confirmed diagnosis of prevalent Multiple Sclerosis (MS) in the previous 3 years, and controls (n = 607) were apparently healthy individuals matched on sex and age (42 ± 4 years). A validated Arabic food frequency questionnaire (FFQ) was utilized to obtain estimated dietary intake. Dietary data from the FFQ were analyzed using ESHA's Food Processor® nutrition analysis software, and the results were used to calculate the DII scores. Logistic regression analyses, controlling for covariates such as age, sex, body mass index, and smoking status, were used to measure the association between DII score and MS outcomes. Results Cases represent a mixed sample of MS phenotypes and controls were comparable on age and sex. However, controls tended to be taller, lighter, had a lower BMI, and had a lower smoking rate. After controlling for age, BMI, sex, and smoking status, there was a consistent increase in MS risk according to DII score, with a 10-fold increase in odds in quartile 4 vs. quartile 1 [ORquartile 4vs1 = 10.17 (95% CI: 6.88; 15.04)]. For each point increase in DII score, there was nearly a doubling of odds [OR1 = 1.75 (95% CI: 1.59; 1.92)]. Individual nutrients and food values aligned according to their contribution to the DII score calculations. Conclusion The findings of this study, obtained in MS patients with varied illness duration over the previous 3 years, are consistent with an association between the overall inflammatory potential of diet and MS odds. Our findings among MS participants showed a significantly more pro-inflammatory DII scores than age- and sex-matched controls. Our results also suggest that MS group had a diet rich in pro-inflammatory foods and nutrients.
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Affiliation(s)
- Omar A. Alhaj
- Department of Nutrition, Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan
| | - Khaled Trabelsi
- High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | | | - Nitin Shivappa
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
- The Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, United States
- Department of Nutrition, Connecting Health Innovations LLC, Columbia, SC, United States
| | - Nicola L. Bragazzi
- Laboratory for Industrial and Applied Mathematics, Department of Statistics, York University, Toronto, ON, Canada
- Human Nutrition Unit, Department of Food and Drugs, University of Parma Medical School, Parma, Italy
| | - James R. Hebert
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
- The Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, United States
- Department of Nutrition, Connecting Health Innovations LLC, Columbia, SC, United States
| | - Haitham A. Jahrami
- Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
- Ministry of Health, Government Hospitals, Manama, Bahrain
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Arji G, Rezaeizadeh H, Moghadasi AN, Sahraian MA, Karimi M, Alizadeh M. Complementary and alternative therapies in multiple sclerosis: a systematic literature classification and analysis. Acta Neurol Belg 2022; 122:281-303. [PMID: 35060096 DOI: 10.1007/s13760-021-01847-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND AIM Multiple Sclerosis (MS) is a disease determined by inflammatory demyelination and neurodegeneration in the Central Nervous System (CNS). Despite the extensive utilization of Complementary and Alternative Medicine (CAM) in MS, there is a need to have comprehensive evidence regarding their application in the management of MS symptoms. This manuscript is a Systematic Literature Review and classification (SLR) of CAM therapies for the management of MS symptoms based on the International Classification of Functioning Disability and Health (ICF) model. METHOD Studies published between 1990 and 2020 IN PubMed, Science Direct, Scopus, Pro-Quest, and Google Scholar using CAM therapies for the management of MS symptoms were analyzed. RESULTS Thirty-one papers on the subject were analyzed and classified. The findings of this review clearly show that mindfulness, yoga, and reflexology were frequently used for managing MS symptoms. Moreover, most of the papers used mindfulness and yoga as a CAM therapy for the management of MS symptoms, which mostly devoted to mental functions such as fatigue, depression, cognition, neuromuscular functions such as gait, muscle strength, and spasticity, and sensory function such as balance, in addition to, reflexology is vastly used to management of mental functions of MS patients. CONCLUSION Evidence suggested that CAM therapies in patients with MS have the potential to target and enhancement numerous elements outlined in the ICF model. Although the use of CAM therapies in MS symptom management is promising, there is a need for strict clinical trials. Future research direction should concentrate on methodologically powerful studies to find out the potential efficacy of CAM intervention.
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Affiliation(s)
- Goli Arji
- School of Nursing and Midwifery, Health Information Technology Department, Saveh University of Medical Sciences, Saveh, Iran
| | - Hossein Rezaeizadeh
- Department of Persian Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Abdolrreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Karimi
- Department of Persian Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Mojtaba Alizadeh
- Department of Computer Engineering, Lorestan University, Khorramabad, Iran.
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Parks NE, Jackson-Tarlton CS, Vacchi L, Merdad R, Johnston BC. Dietary interventions for multiple sclerosis-related outcomes. Cochrane Database Syst Rev 2020; 5:CD004192. [PMID: 32428983 PMCID: PMC7388136 DOI: 10.1002/14651858.cd004192.pub4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is a common demyelinating disease of the central nervous system. Although the exact pathogenesis remains unknown, the leading theory is that it results from immune system dysregulation. Approved disease-modifying therapy appears to modulate the immune system to improve MS-related outcomes. There is substantial interest in the ability of dietary interventions to influence MS-related outcomes. This is an update of the Cochrane Review 'Dietary interventions for multiple sclerosis' (Farinotti 2003; Farinotti 2007; Farinotti 2012). OBJECTIVES To assess the effects of dietary interventions (including dietary plans with recommendations for specific whole foods, macronutrients, and natural health products) compared to placebo or another intervention on health outcomes (including MS-related outcomes and serious adverse events) in people with MS. SEARCH METHODS On 30 May 2019, we searched CENTRAL, MEDLINE, Embase, and Web of Science. We also searched ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (ICTRP), and Networked Digital Library of Theses and Dissertations (NDLTD). We checked reference lists in identified trials and requested information from trial authors to identify any additional published or unpublished data. SELECTION CRITERIA We included any randomized controlled trial (RCT) or controlled clinical trial (CCT) examining the effect of a dietary intervention versus placebo or another intervention among participants with MS on MS-related outcomes, including relapses, disability progression, and magnetic resonance imaging (MRI) measures. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Planned primary outcomes were number of participants experiencing relapse and change in disability progression, according to a validated disability scale at the last reported follow-up. Secondary outcomes included MRI activity, safety, and patient-reported outcomes. We entered and analysed data in Review Manager 5. MAIN RESULTS We found 41 full-text articles examining 30 trials following full-text review. Participants were adults with MS, defined by established criteria, presenting to MS clinics in Europe, North America, and the Middle East. Study design varied considerably, although all trials had at least one methodological issue leading to unknown or high risk of bias. Trials examined: supplementation to increase polyunsaturated fatty acids (PUFAs) (11 trials); a variety of antioxidant supplements (10 trials); dietary programmes (3 trials); and other dietary supplements (e.g. acetyl L-carnitine, biotin, creatine, palmitoylethanolamide, probiotic, riboflavin) (6 trials). In three trials comparing PUFAs with monounsaturated fatty acids (MUFAs), the evidence was very uncertain concerning difference in relapses (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.88 to 1.20; 3 studies, 217 participants; 75% in the PUFA group versus 74% in the MUFA group; very low-certainty evidence). Among four trials comparing PUFAs with MUFAs, there may be little to no difference in global impression of deterioration (RR 0.85, 95% CI 0.71 to 1.03; 4 studies, 542 participants; 40% in the PUFA group versus 47% in the MUFA group; low-certainty evidence). In two trials comparing PUFAs with MUFAs (102 participants), there was very low-certainty evidence for change in disability progression. None of the PUFA versus MUFA trials examined MRI outcomes. In one trial comparing PUFAs with MUFAs (40 participants), there were no serious adverse events; based on low-certainty evidence. In two trials comparing different PUFAs (omega-3 versus omega-6), there may be little to no difference in relapses (RR 1.02, 95% CI 0.62 to 1.66; 2 studies, 129 participants; 30% in the omega-3 versus 29% in the omega-6 group; low-certainty evidence). Among three trials comparing omega-3 with omega-6, there may be little to no difference in change in disability progression, measured as mean change in Expanded Disability Status Scale (EDSS) (mean difference (MD) 0.00, 95% CI -0.30 to 0.30; 3 studies, 166 participants; low-certainty evidence). In one trial comparing omega-3 with omega-6, there was likely no difference in global impression of deterioration (RR 0.99, 95% CI 0.51 to 1.91; 1 study, 86 participants; 29% in omega-3 versus 29% in omega-6 group; moderate-certainty evidence). In one trial comparing omega-3 with omega-6 (86 participants), there was likely no difference in number of new T1- weighted gadolinium-enhancing lesions, based on moderate-certainty evidence. In four trials comparing omega-3 with omega-6, there may be little to no difference in serious adverse events (RR 1.12, 95% CI 0.38 to 3.31; 4 studies, 230 participants; 6% in omega-3 versus 5% in omega-6 group; low-certainty evidence). In four trials examining antioxidant supplementation with placebo, there may be little to no difference in relapses (RR 0.98, 95% CI 0.59 to 1.64; 4 studies, 345 participants; 17% in the antioxidant group versus 17% in the placebo group; low-certainty evidence). In six trials examining antioxidant supplementation with placebo, the evidence was very uncertain concerning change in disability progression, measured as mean change of EDSS (MD -0.19, 95% CI -0.49 to 0.11; 6 studies, 490 participants; very low-certainty evidence). In two trials examining antioxidant supplementation with placebo, there may be little to no difference in global impression of deterioration (RR 0.99, 95% 0.50 to 1.93; 2 studies, 190 participants; 15% in the antioxidant group versus 15% in the placebo group; low-certainty evidence). In two trials examining antioxidant supplementation with placebo, the evidence was very uncertain concerning difference in gadolinium-enhancing lesions (RR 0.67, 95% CI 0.09 to 4.88; 2 studies, 131 participants; 11% in the antioxidant group versus 16% in the placebo group; very low-certainty evidence). In three trials examining antioxidant supplementation versus placebo, there may be little to no difference in serious adverse events (RR. 0.72, 95% CI 0.17 to 3.08; 3 studies, 222 participants; 3% in the antioxidant group versus 4% in the placebo group; low-certainty evidence). AUTHORS' CONCLUSIONS There are a variety of controlled trials addressing the effects of dietary interventions for MS with substantial variation in active treatment, comparator, and outcomes of interest. PUFA administration may not differ when compared to alternatives with regards to relapse rate, disability worsening, or overall clinical status in people with MS, but evidence is uncertain. Similarly, at present, there is insufficient evidence to determine whether supplementation with antioxidants or other dietary interventions have any impact on MS-related outcomes.
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Key Words
- adult
- humans
- antioxidants
- antioxidants/administration & dosage
- diet, fat-restricted
- diet, paleolithic
- diet, vegetarian
- dietary supplements
- disease progression
- fatty acids, monounsaturated
- fatty acids, monounsaturated/therapeutic use
- fatty acids, omega-3
- fatty acids, omega-3/administration & dosage
- fatty acids, omega-6
- fatty acids, omega-6/administration & dosage
- fatty acids, unsaturated
- fatty acids, unsaturated/administration & dosage
- multiple sclerosis
- multiple sclerosis/diet therapy
- randomized controlled trials as topic
- recurrence
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Affiliation(s)
- Natalie E Parks
- Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada
| | | | - Laura Vacchi
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Roah Merdad
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Bradley C Johnston
- Department of Nutrition, Texas A&M University, College Station, Texas, USA
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Effects of osteopathic manipulative treatment on patients with multiple sclerosis: A pilot study. Complement Ther Med 2019; 43:154-156. [PMID: 30935523 DOI: 10.1016/j.ctim.2019.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To describe the effects of osteopathic manipulative treatment in patients affected by Multiple Sclerosis (MS). DESIGN AND SETTING This is a pilot study involving 20 MS patients attending the IRCCS Neurolesi "Bonino-Pulejo", Messina, Italy. INTERVENTION The clinical evaluation was performed before starting rehabilitation treatment (T0) and after 8 weeks of treatment (T1). The CG sample undergo a conventional rehabilitation training (CRT), 5 times/week for 60 min (for a total of 40 sessions), the EG performed the same CRT (but with a different frequency, i.e. 3 times/week, for a total of 24 sessions) and a specific OMT 2 times/week for 60 min (for a total of 16 sessions). MAIN OUTCOME MEASURES We analyzed the scores recorded in the following main scales: Expanded Disability Status Scale (EDSS), 10 m walking test (10mWT), Hamilton anxiety rating scale (HRS-A), and the Fatigue severity scale (FSS). RESULTS Our data showed a reduction in the FSS score for the EG (40 ± 1,41 at T0 vs 37 ± 2,32 at T1; p = 0.04) but not in the CG (41 ± 2,41 at TO vs 39 ± 2,6 at T1) with an intergroup difference p < 0.00. An improvement of HRS-A and 10mWT was also detected in the EG. CONCLUSIONS Our data raise idea that OMT might be useful in rehabilitative setting in MS patients, with particular regard to anxiety and fatigue.
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Namjooyan F, Ghanavati R, Majdinasab N, Jokari S, Janbozorgi M. Uses of complementary and alternative medicine in multiple sclerosis. J Tradit Complement Med 2014; 4:145-52. [PMID: 25161918 PMCID: PMC4142451 DOI: 10.4103/2225-4110.136543] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, disabling, recurrent demyelination of the central nervous system (CNS). It could affect different regions in the brain and spinal cord, and according to the domain which is affected, it could cause different symptoms such as motor, sensory, or visual impairment; fatigue; bowel, bladder, and sexual dysfunction; cognitive impairment; and depression. MS patients also face reduced quality of life. Drugs that are used in MS are not fully efficient and patients suffer from many symptoms and adverse effects. Today there is an increasing trend of using complementary and alternative medicine (CAM). People are more likely to use this type of treatment. Using appropriate lifestyle and CAM therapy can subside some of the symptoms and could improve the quality of life in these patients. Many people with MS explore CAM therapies for their symptoms. This review is aimed to introduce CAM therapies that could be used in MS patients.
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Affiliation(s)
- Foroogh Namjooyan
- Department of Pharmacognosy, Marine Natural Pharmaceutical Research Center, School of Pharmacy, Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Rahil Ghanavati
- Department of Traditional Pharmacy, School of Pharmacy, Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nastaran Majdinasab
- Department of Neurology, School of Medicine, Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shiva Jokari
- Jundishapur University of Medical Sciences, Arvand International Branch, Abadan, Iran
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Helal SI, Hegazi A, Al-Menabbawy K. Apitherapy Have a Role in Treatment of Multiple Sclerosis. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM: Multiple sclerosis (MS) is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged. We Study the effect of Apitherapy in treatment of MS.MATERIAL AND METHODS: Fifty patients with MS, their ages ranged between 26-71 years, were subjected to complete clinical and neurological history and examination to confirm the diagnosis. All cases were under their regular treatment they were divided into two main groups, Group I received honey, pollen, royal jelly and propolis and were treated with apiacupuncture 3 times weekly, for 12 months, in addition to their medical treatment, while group II remains on their ordinary medical treatment only. Apiacupuncture was done by bee stings for regulating the immune system.RESULTS: Results revealed that 4 patients showed some improvement regarding their defects in gait, bowel control, constipation and urination, while 12 cases, showed some mild improvement in their movement in bed, and better improvement in bed sores, sensation, and better motor power, only two cases of them were able to stand for few minutes with support.CONCLUSION: Although Apitherapy is not a curable therapy in MS, but it can be used to minimize the clinical symptoms of MS, and can be included among programs of MS therapy.
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Kochs L, Wegener S, Sühnel A, Voigt K, Zettl UK. The use of complementary and alternative medicine in patients with multiple sclerosis: A longitudinal study. Complement Ther Med 2014; 22:166-72. [DOI: 10.1016/j.ctim.2013.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 11/08/2013] [Accepted: 11/21/2013] [Indexed: 11/17/2022] Open
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Skovgaard L, Nicolajsen P, Pedersen E, Kant M, Fredrikson S, Verhoef M, Meyrowitsch D. People with multiple sclerosis in Denmark who use complementary and alternative medicine—Do subgroups of patients differ? Eur J Integr Med 2013. [DOI: 10.1016/j.eujim.2013.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Farinotti M, Vacchi L, Simi S, Di Pietrantonj C, Brait L, Filippini G. Dietary interventions for multiple sclerosis. Cochrane Database Syst Rev 2012; 12:CD004192. [PMID: 23235605 DOI: 10.1002/14651858.cd004192.pub3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Clinical and experimental data suggest that certain dietary regimens, particularly those including polyunsaturated fatty acids (PUFAs) and vitamins, might improve outcomes in people with multiple sclerosis (MS). Diets and dietary supplements are much used by people with MS in the belief that they might improve disease outcomes and overcome the effectiveness limits of conventional treatments.This is an update of the Cochrane review "Dietary intervention for multiple sclerosis" (first published on The Cochrane Library 2007, Issue 1). OBJECTIVES To answer MS patients' questions regarding the efficacy and safety of dietary regimens for MS. Can changes in dietary habits be an effective intervention for MS patients? Are the potential side effects of these interventions known, and have they been measured? Are potential interactions between dietary interventions and other curative or symptomatic treatments known and have they been studied? SEARCH METHODS We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register (November 2011), CENTRAL (The Cochrane Library 2011, Issue 4), MEDLINE (PubMed) (1966 to November 2011), EMBASE (embase.com) (1974 to November 2011) and reference lists of papers found. SELECTION CRITERIA All controlled trials (randomised controlled trials (RCTs) and controlled clinical trials (CCTs)) on a specific dietary intervention, diet plan or dietary supplementation, except for vitamin D supplementation, compared to no dietary modification or placebo were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently selected articles, assessed trial quality and extracted data. Data were entered and analysed in RevMan.Dichotomous data were summarised as relative risks (RR) with 95% confidence intervals (95% CI) using a random-effects model in the presence of heterogeneity (I² > 60%). Continuous data were analysed using weighted mean differences, determined by the difference between the pre- and post-intervention changes in the treatment and control groups. MAIN RESULTS Six RCTs that investigated PUFAs emerged from the search strategy, accounting for 794 randomised patients.PUFAs did not have a significant effect on disease progression at 24 months. Omega-6 fatty acids (11 to 23 g/day linoleic acid) didn't show any benefit in 144 MS patients (RR 1.04, 95% CI 0.66 to 1.63). Linoleic acid (2.9 to 3.4 g/day) had no benefit in 65 chronic progressive MS patients (RR 0.78, 95% CI 0.43 to 1.42). Omega-3 fatty acids had no benefit in 292 relapsing remitting MS patients (RR 0.82, 95% CI 0.65 to 1.03, P = 0.08).Slight potential benefits in relapse outcomes were associated with omega-6 fatty acids in some studies, however these findings were limited by the reduced validity of the endpoints. No judgements about safety or patient-reported outcomes were possible. In general, trial quality was poor.No studies on vitamin supplementation and allergen-free diets were analysed as none met the eligibility criteria, mainly due to lack of clinical outcomes. AUTHORS' CONCLUSIONS PUFAs seem to have no major effect on the main clinical outcome in MS (disease progression), but they may tend to reduce the frequency of relapses over two years. However, the data that are available are insufficient to assess a real benefit or harm from PUFA supplementation because of their uncertain quality.Evidence on the possible benefits and risks of vitamin supplementation and antioxidant supplements in MS is lacking. More research is required to assess the effectiveness of dietary interventions in MS.
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Affiliation(s)
- Mariangela Farinotti
- Neuroepidemiology Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milano, Italy.
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Use of Complementary and Alternative Medicine among People with Multiple Sclerosis in the Nordic Countries. Autoimmune Dis 2012; 2012:841085. [PMID: 23304461 PMCID: PMC3529905 DOI: 10.1155/2012/841085] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 09/22/2012] [Accepted: 09/22/2012] [Indexed: 11/17/2022] Open
Abstract
Aims. The aim of the study was to describe and compare (1) the types and prevalence of complementary and alternative medicine (CAM) treatments used among individuals with multiple sclerosis (MS) in the Nordic countries; (2) the types of conventional treatments besides disease-modifying medicine for MS that were used in combination with CAM treatments; (3) the types of symptoms/health issues addressed by use of CAM treatments. Methods. An internet-based questionnaire was used to collect data from 6455 members of the five Nordic MS societies. The response rates varied from 50.9% in Norway to 61.5% in Iceland. Results. A large range of CAM treatments were reported to be in use in all five Nordic countries. Supplements of vitamins and minerals, supplements of oils, special diet, acupuncture, and herbal medicine were among the CAM treatment modalities most commonly used. The prevalence of the overall use of CAM treatments within the last twelve months varied from 46.0% in Sweden to 58.9% in Iceland. CAM treatments were most often used in combination with conventional treatments. The conventional treatments that were most often combined with CAM treatment were prescription medication, physical therapy, and over-the-counter (OTC) medications. The proportion of CAM users who reported exclusive use of CAM (defined as use of no conventional treatments besides disease-modifying medicine for MS) varied from 9.5% in Finland to 18.4% in Norway. In all five Nordic countries, CAM treatments were most commonly used for nonspecific/preventative purposes such as strengthening the body in general, improving the body's muscle strength, and improving well-being. CAM treatments were less often used for the purpose of improving specific symptoms such as body pain, problems with balance, and fatigue/lack of energy. Conclusions. A large range of CAM treatments were used by individuals with MS in all Nordic countries. The most commonly reported rationale for CAM treatment use focused on improving the general state of health. The overall pattern of CAM treatment use was similar across the five countries.
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Abstract
Complementary and alternative medicine (CAM) is used by one-half to three-fourths of patients with multiple sclerosis (MS). Despite this widespread use, CAM may not be discussed in the course of a conventional medical visit. When considered in the context of MS, CAM therapies have a wide range of risk-benefit profiles. Some CAM therapies, such as acupuncture, cranberry, vitamin D, tai chi, and yoga, are low risk and possibly beneficial. Other CAM therapies, such as immune-stimulating supplements, bee venom, and hyperbaric oxygen, are ineffective, dangerous, or unstudied. Providing access to information about the risks and benefits of CAM therapies may increase the quality of care that is provided to patients with MS.
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von Geldern G, Mowry EM. The influence of nutritional factors on the prognosis of multiple sclerosis. Nat Rev Neurol 2012; 8:678-89. [PMID: 23026980 DOI: 10.1038/nrneurol.2012.194] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The effect of nutrition and dietary supplements on the course of multiple sclerosis (MS) is a topic of great interest to both patients and clinicians. In particular, vitamin D status has been shown to influence both the incidence and the course of MS. High vitamin D levels are probably protective against the development of MS, although the efficacy of vitamin D supplementation in slowing progression of MS remains to be established. The influence of polyunsaturated fatty acids (PUFAs) on the development and course of MS has also long been under investigation. Small clinical trials suggest a modest reduction in the severity and duration of relapses in patients with MS receiving PUFA supplements. Other nutritional factors have been evaluated for their effect on MS disease progression, including milk proteins, gluten, probiotics, antioxidants (uric acid, vitamins A, C and E, lipoic acid), polyphenols, Ginkgo biloba extracts and curcumin. However, further studies are needed to evaluate the effects of these dietary components on the relapse rate and progression of MS. This Review gives an overview of the literature on the nutritional factors most commonly implicated as having an effect on MS and discusses the biological rationale that is thought to underlie their influence.
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Affiliation(s)
- Gloria von Geldern
- Department of Neurology, Division of Neuroimmunology and Neurological Infections, John Hopkins University School of Medicine, Pathology Building Room 627, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Abstract
Complementary and alternative medicine (CAM) is used by one-half to three-fourths of multiple sclerosis (MS) patients. Although it is used widely, CAM may not be discussed during a conventional medical visit. In MS, CAM therapies exhibit a broad range of risk-benefit profiles; some of these therapies are low risk and possibly beneficial, whereas others are ineffective, dangerous, or unstudied. Health professionals who provide objective and practical information about the risks and benefits of CAM therapies may improve the quality of care for those with MS.
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Affiliation(s)
- Allen C Bowling
- MS Service, Colorado Neurological Institute, 701 East Hampden Avenue, #320, Englewood, CO 80113, USA.
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Ginsburg I, Rozenstein-Tsalkovich L, Koren E, Rosenmann H. The herbal preparation Padma® 28 protects against neurotoxicity in PC12 cells. Phytother Res 2011; 25:740-3. [PMID: 21413090 DOI: 10.1002/ptr.3459] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 02/01/2011] [Accepted: 02/02/2011] [Indexed: 11/06/2022]
Abstract
Padma® 28 is a multicompound herbal preparation based on the camphor formulas from traditional Tibetan medicine (TTM). It contains a variety of different secondary plant substances, which include terpenes and polyphenols such as flavonoids and tannins. As a rich source of antioxidant polyphenols, this herbal Padma 28 preparation seems to be a promising candidate for the treatment of degenerative diseases such as Alzheimer's disease (AD), a condition involving oxidative stress. Moreover, polyphenols have also been shown to mitigate AD neuropathology. The study investigated the protective effect of Padma 28 and of certain polyphenols on the neurotoxicity of PC12 cells induced by the neurotoxins: amyloid-beta (Aβ), glutamate, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and 3-nitropropionate (3-NP), known to be involved in AD, Parkinson's disease (PD), amyotrophic-lateral-sclerosis (ALS) and Huntington's disease (HD), respectively. The decrease in cell viability induced by each of the toxins was significantly attenuated by Padma 28 treatment. Also, a decrease in the oxidative capacity of PC12 cells treated with Padma 28 was noted, indicating that the decrease in cell viability induced by the toxins might have been the result of an oxidative stress which could be attenuated by Padma 28 acting as a potent antioxidant. Padma 28, which is available in Europe and USA, seems to be a promising candidate for the treatment of CNS diseases.
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Affiliation(s)
- Isaac Ginsburg
- Dental Research, Faculty of Dental Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Esmonde L, Long AF. Complementary therapy use by persons with multiple sclerosis: benefits and research priorities. Complement Ther Clin Pract 2008; 14:176-84. [PMID: 18640629 DOI: 10.1016/j.ctcp.2008.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
People with multiple sclerosis (MS) are commonly actively involved in self-care, with many accessing complementary and alternative medicine (CAM) to help in symptom management. To provide increased insight into benefits from CAM use and service user ideas over research priorities, a two-part study, involving a questionnaire and interactive workshop, was undertaken with attendees at a national Congress of the MS Trust in the UK. The six most used therapies were reflexology, massage, yoga, relaxation and meditation, acupuncture and aromatherapy. Each was rated by a quarter to two-fifths as 'extremely helpful'. Insight into the nature of the therapeutic benefit was provided in user comments. Despite the self-selected nature of the sample, the findings point to potential benefits of a set of CAM therapies in helping people with MS. More research on potential benefits of therapies was called for by participants and on the dynamics of the therapeutic effect.
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Affiliation(s)
- Lisa Esmonde
- School of Healthcare, University of Leeds, Baines Wing, Leeds LS2 9UT, UK
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Hensel M, Zoz M, Ho AD. Complementary and alternative medicine in patients with chronic lymphocytic leukemia. Support Care Cancer 2008; 17:47-52. [DOI: 10.1007/s00520-008-0452-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 04/03/2008] [Indexed: 11/24/2022]
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Marmarou A, Young HF, Aygok GA. Estimated incidence of normal-pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities. Neurosurg Focus 2007; 22:E1. [PMID: 17613187 DOI: 10.3171/foc.2007.22.4.2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The primary objective of this study was to estimate the prevalence of idiopathic normal-pressure hydrocephalus (NPH), both diagnosed and undiagnosed, among residents of assisted-living and extended-care facilities, by using a practical screening tool. A secondary objective was to evaluate prospectively the diagnosis and outcome of surgical treatment in a subset of patients residing in healthcare facilities who were at risk for idiopathic NPH.
Methods
A retrospective chart analysis was performed using the medical records from four nursing homes. The final analysis included 147 patient records. Symptomatology and comorbidity were evaluated, as was the ability to perform activities of daily living. In a subset of 17 patients residing in healthcare facilities, the authors applied a standard idiopathic NPH diagnostic and management protocol and followed up the patients 1 year after treatment.
The estimated incidence of suspected idiopathic NPH among all patients in the retrospective survey ranged from 9 to 14%, depending on the diagnostic criteria used. Among the cohort of 17 patients available for an in-hospital study and 1-year follow up, 11 received shunts and seven of these showed either transient or sustained improvement.
Conclusions
A valid and practical diagnostic method is needed to identify idiopathic NPH accurately before admitting patients to a healthcare facility. Data from a prospective study of 17 patients residing in healthcare facilities indicated that supplementary tests remain predictive of a positive response to shunt insertion but cannot predict whether a favorable outcome will be sustained in a population of patients who have been confined to a wheelchair for a prolonged period of time. This finding supports the notion of a finite window of opportunity for successful treatment of idiopathic NPH and the imperativeness of an early diagnosis.
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Affiliation(s)
- Anthony Marmarou
- Department of Neurosurgery, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0508, USA.
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Mohammad S M, Taleban F, Kimiagar S, Ghafarpoor M. Dietary Supplementation in Iranian Multiple Sclerosis Patients. JOURNAL OF MEDICAL SCIENCES 2007. [DOI: 10.3923/jms.2007.413.417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Farinotti M, Simi S, Di Pietrantonj C, McDowell N, Brait L, Lupo D, Filippini G. Dietary interventions for multiple sclerosis. Cochrane Database Syst Rev 2007:CD004192. [PMID: 17253500 DOI: 10.1002/14651858.cd004192.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Clinical and experimental data suggest that certain dietary regimens, particularly those including polyunsaturated fatty acids (PUFAs) and vitamins might improve outcomes in people with multiple sclerosis (MS). Diets and dietary supplements are much used by people with MS in the belief that they might improve disease outcomes. OBJECTIVES We performed a Cochrane review of all randomised trials of dietary regimens for MS with the aim of answering MS consumers' questions regarding the efficacy and safety of these interventions. SEARCH STRATEGY We searched the Cochrane MS Group trial register (February 2006), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library, Issue 1, 2006, MEDLINE (PubMed) (1966 to March 2006), EMBASE (1974 to March 2006) and the bibliographies of papers found. SELECTION CRITERIA All randomised controlled trials comparing a specific dietary intervention, diet plan or dietary supplementation, with no dietary modification or placebo, were eligible. DATA COLLECTION AND ANALYSIS Two reviewers independently selected articles, assessed trial quality and extracted data. Trial quality was poor, particularly as regards descriptions of randomisation, blinding and adverse event reporting. Some studies had large numbers of drop-outs; dropouts were never included in the analyses. MAIN RESULTS PUFAs did not have a significant effect on disease progression, measured as worsening of Disability Status Scale. Omega-6 fatty acids (11-23 g/day linoleic acid) had no benefit in 75 relapsing remitting (RR) MS patients (progression at two years: relative risk (RR)=0.78, 95% CI [0.45 to 1.36]) or in 69 chronic progressive (CP) MS patients (RR=1.67, 95% CI [0.75 to 3.72]. Linoleic acid (2.9-3.4 g/day) had no benefit in CPMS (progression at two years: RR=0.78, 95% CI [0.43 to 1.42]). Slight decreases in relapse rate and relapse severity were associated with omega-6 fatty acids in some small studies, however these findings are limited by the limited validity of the endpoints.Omega-3 fatty acids had no benefit on progression at 12 months in 14 RRMS patients or at 24 months in 292 RRMS patients (RR=0.15, 95% CI [0.01 to 3.11], p= 0.22 at 12 months, and 0.82 95% CI [0.65 to 1.03], p=0.08, at 24 months). The low frequency of reported adverse events suggests no major toxicity associated with PUFA administration. No studies on vitamin supplementation and allergen-free diets were analysed as none met the eligibility criteria. AUTHORS' CONCLUSIONS PUFAs seem to have no major effect on the main clinical outcome in MS (disease progression), and does not substantially affect the risk of clinical relapses over 2 years. However, the data available are insufficient to assess any potential benefit or harm from PUFA supplementation. Evidence bearing on the possible benefits and risks of vitamin supplementation and antioxidant supplements in MS is lacking. More research is required to assess the effectiveness of diets interventions in MS.
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Affiliation(s)
- M Farinotti
- Istituto Nazionale Neurologico Carlo Besta, S.O. Neuroepidemiologia, via Celoria 11, Milano (MI), Italy, 20133.
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Yadav V, Bourdette D. Complementary and alternative medicine: is there a role in multiple sclerosis? Curr Neurol Neurosci Rep 2007; 6:259-67. [PMID: 16635436 DOI: 10.1007/s11910-006-0014-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite effective conventional therapies for multiple sclerosis (MS), many people with MS explore complementary and alternative medicine (CAM) therapies for their symptoms. Common CAM therapies that people use include dietary modification, nutritional and herbal supplementation, and mind-body therapies. There is a revival of interest among MS researchers about the therapeutic potential of low-fat diet and essential fatty acid supplementation in MS. The efficacy of specific vitamin supplementation remains unclear. Recently, cannabis and yoga have been studied in more controlled studies and have provided evidence that they may have some benefit. The research on CAM therapies in MS is still exploratory, but considering peoples' interest and common use of these therapies, further research in this area is clearly warranted.
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Affiliation(s)
- Vijayshree Yadav
- Department of Neurology L226, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Johnson SK, Diamond BJ, Rausch S, Kaufman M, Shiflett SC, Graves L. The effect of Ginkgo biloba on functional measures in multiple sclerosis: a pilot randomized controlled trial. Explore (NY) 2006; 2:19-24. [PMID: 16781604 DOI: 10.1016/j.explore.2005.10.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic demyelinating neurological disease afflicting young and middle-aged adults, resulting in problems with coordination, strength, cognition, affect, and sensation. OBJECTIVE The objective of this study was to determine whether a ginkgo extract (EGb 761) improved functional performance in individuals with MS. DESIGN This study used a double-blind, placebo-controlled, parallel group design. The end point was change between baseline (ie, preintervention) and follow-up evaluation following a regimen of four tablets per day at 60 mg per tablet for four weeks. SETTING The study was conducted in academic and clinical-based settings. PATIENTS/PARTICIPANTS Twenty-two individuals with MS were randomly assigned to either the treatment or control condition. Groups did not differ with respect to age, IQ, and education. INTERVENTION Half of the subjects received 240 mg per day of ginkgo special extract (EGb 761), and the other half received placebo. MAIN OUTCOME MEASURE The main outcome measures assessed depression (Center for Epidemiologic Studies of Depression Scale [CES-D]), anxiety (State-Trait Anxiety Inventory [STAI]), fatigue (Modified Fatigue Impact Scale [MFIS]); symptom severity (Symptom Inventory [SI]) and functional performance (Functional Assessment of Multiple Sclerosis [FAMS]). RESULTS The ginkgo group had significantly more individuals showing improvement on four or more measures with improvements associated with significantly larger effect sizes on measures of fatigue, symptom severity, and functionality. The ginkgo group also exhibited less fatigue at follow-up compared with the placebo group. CONCLUSIONS This exploratory pilot study showed that no adverse events or side effects were reported and that ginkgo exerted modest beneficial effects on select functional measures (eg, fatigue) among some individuals with MS.
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Apel A, Greim B, König N, Zettl UK. Frequency of current utilisation of complementary and alternative medicine by patients with multiple sclerosis. J Neurol 2006; 253:1331-6. [PMID: 16786211 DOI: 10.1007/s00415-006-0217-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 03/02/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of the study was to examine the frequency and characteristics of complementary and alternative medicine (CAM) use among patients with multiple sclerosis (MS). METHOD In order to collect sociodemographic and disease related variables as well as aspects of CAM utilisation 254 MS patients were examined with an interview. The investigation was completed by data of the neurological examination. RESULTS At the time of investigation 67.3% of the MS patients reported that they were currently using one or more CAMs. Overall, most of the overall utilized therapies (90.6%) were chosen as a complement and 9.4% as an alternative therapy. Users of complementary medicine were more severely affected by the MS than non-users and had a longer duration of illness. No sociodemographic differences were found between users and non-users. When evaluating the efficacy of CAM, patients reported improvement in 67.1%, no influence in 32.3% and worsening in 0.6% of the cases. 3.7% of the CAM therapies were accompanied by minor side effects. CONCLUSIONS Since MS patients are frequently using CAM despite the absence of clinically proven efficacy and appraise it positively, further research on the motivation for utilisation and on objective effects of CAM are needed.
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Affiliation(s)
- Annett Apel
- Department of Neurology, University of Rostock, Gehlsheimer Str. 20, 18147, Rostock, Germany.
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Abstract
Benefits from any particular diet in multiple sclerosis (MS) have not yet been proven. It is, however, frequent that malnutrition may potentially exacerbate the symptoms of MS. There is some evidence that a high intake of saturated fat increases the incidence of MS. Epidemiological studies imply that unsaturated fatty acids may have a positive effect on the course of MS. However, the results of controlled studies are ambiguous. A meta-analysis of three small controlled clinical trials suggests a benefit from linoleic acid. Intake of Vitamin D is associated with a lower incidence of MS. In MS, the risk of osteoporosis is high, and prophylactic vitamin D and calcium should be considered at an early stage. The role of minerals, trace elements, antioxidants, vitamins or fish oil is unclear. The possible relationships between diet and MS have not been subjected to adequate study. It seems possible that in the future, diets or dietary supplements may become recommended forms of treatment for MS.
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Affiliation(s)
- Stefan Schwarz
- Department of Neurology, Klinikum Mannheim of the University of Heidelberg, Mannheim 68167, Germany.
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Abstract
Beneficial effects from any particular diet have not been proven in multiple sclerosis (MS). Therefore, the general guidelines on nutrition should be followed. Obesity and various forms of malnutrition worsening the MS symptoms are frequently observed. There is some evidence from epidemiological studies that a high consumption of saturated animal fat is associated with an increased incidence of MS. The findings from such studies indicate that supplementation with unsaturated fatty acids, in particular omega-3 fatty acids, could positively influence the course of MS. However, controlled studies did not show clear beneficial effects from polyunsaturated fatty acids. The intake of vitamin D is associated with a lower incidence of MS. In contrast, the effects of therapy with vitamin D on the course of MS have not been ascertained. Patients with MS carry an enormous risk of osteoporosis, and therefore the indication for a preventive therapy with vitamin D and calcium should be established in every postmenopausal woman or after repeated steroid treatments.
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Affiliation(s)
- S Schwarz
- Neurologische Klinik, Klinikum Mannheim der Universität Heidelberg, 68135 Mannheim.
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&NA;. QUINTEssentials®. Continuum (Minneap Minn) 2004. [DOI: 10.1212/01.con.0000293637.00604.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Affiliation(s)
- John J Bright
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA.
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Pucci E, Cartechini E, Taus C, Giuliani G. Why physicians need to look more closely at the use of complementary and alternative medicine by multiple sclerosis patients. Eur J Neurol 2004; 11:263-7. [PMID: 15061828 DOI: 10.1046/j.1468-1331.2003.00758.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
With the aim of contributing to the knowledge of attitudes, patterns and motivations for the use of complementary and alternative medicine (CAM) for multiple sclerosis (MS), 109 MS outpatients, or their close relative in cases of mental status impairment, were interviewed using a semi-structured questionnaire. The main results are: (i). 35.7% used at least one CAM at least once; (ii). homeopathy and diets were the most common; (iii). 39.4% showed a positive attitude towards CAM; (iv). a perceived benefit was recorded in 61.5% of cases; (v). the referral source was a physician in only 12.8% of cases; (vi). caring neurologist was not consulted in 82% and generalist was not consulted in 67% of cases; (vii). of 61 CAM interventions, 21 were expected to be disease-modifying and 40 symptomatic; (viii). CAM negatively influenced compliance with conventional medical management in very few cases (2/39); (ix). a higher expanded disability status scale (EDSS) was observed in CAM users; and (x). in those who used CAM during last 3 years (21.1%), the approximate mean cost per year per person was 483 euro. In Italy, the use of CAM in MS is widespread but costly. This study has provided further baseline data on which to assess trends in CAM use and has highlighted issues for patients and conventional doctors about the use of CAM to deal with health problems. More research into the implications of concurrent use of CAM with conventional medicine on public health care is required.
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Affiliation(s)
- E Pucci
- U O Neurologia, Macerata, Italy.
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