Cigarette Smoking, Alcohol Consumption and Overweight in Multiple Sclerosis: Disability Progression

Environmental factors related to multiple sclerosis progression

Multiple Sclerosis (MS) is a complex neurological disease which prevalence is increasing worldwide. The impact of environmental factors on MS susceptibility has already been defined and highlighted in many previous reports, particularly vitamin D or ultraviolet B light exposure, Epstein-Barr virus (EBV) infection, obesity, and smoking. There is increasing evidence that environmental and lifestyle factors are not only important in triggering MS but are also implicated in MS progression. Low sun exposure and vitamin D deficiency exhibit a strong relationship with disease progression in both animal and human studies. The gestational period seems also to impact long-term disease progression as January's babies had a higher risk of requiring walking assistance than those born in other months. The implication of EBV in neurodegeneration and MS progression was also suggested even though its specific targets and mechanisms are still unclear. Cigarette smoking is correlated with faster clinical progression. The association of obesity and smoking seems to be associated with a faster progression and an increased rate of brain atrophy. Although the effect of air pollution on MS pathogenesis remains not fully understood, exposure to polluted air can stimulate several mechanisms that might contribute to MS severity. People with MS with active disease have an altered microbiota compared to patients in the remission phase. Cardiovascular comorbidities, epilepsy, and depression are also associated with a more severe disability accrual. Knowledge about MS modifiable risk factors of progression need to be incorporated into everyday clinical practice in order to ameliorate disease outcomes.

Association Between Alcohol Consumption and Disability Accumulation in Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Previous studies have indicated that alcohol consumption is associated with multiple sclerosis (MS) disease progression. We aimed to study the influence of alcohol consumption habits on disease progression and health-related quality of life in MS.

METHODS

We categorized patients from 2 population-based case-control studies by alcohol consumption habits at diagnosis and followed them up to 15 years after diagnosis through the Swedish MS registry regarding changes in the Expanded Disability Status Scale (EDSS) and Multiple Sclerosis Impact Scale 29 (MSIS-29). We used Cox regression models with 95% confidence intervals (CIs) using 24-week confirmed disability worsening, EDSS 3, EDSS 4, and physical and psychological worsening from the patient's perspective as end points.

RESULTS

Our study comprised 9,051 patients with MS, with a mean age of 37.5 years at baseline/diagnosis. Compared with nondrinking, low and moderate alcohol consumption was associated with reduced risk of EDSS-related unfavorable outcomes (hazard ratios between 0.81 and 0.90) and with reduced risk of physical worsening. The inverse association was confined to relapsing-remitting MS and was more pronounced among women. High alcohol consumption did not significantly affect disease progression. The inverse relationship between low-moderate alcohol consumption and disability progression became stronger when we only included those who had not changed their alcohol consumption during follow-up (hazard ratios between 0.63 and 0.71). There were no differences in measures of disability at baseline between drinkers who continued drinking alcohol after diagnosis and those who later discontinued. Our findings speak against bias due to reverse causation.

DISCUSSION

Low and moderate alcohol consumption was associated with more favorable outcomes in relapsing-remitting MS, compared with nondrinking, while there was no significant influence of high alcohol consumption on disease outcomes.

Causal effects of dietary composition on multiple sclerosis risk and severity: a Mendelian randomization study

Objectives

Observational studies have found potential associations between dietary intake and multiple sclerosis (MS). However, these associations are inconsistent, and the causal relationship remains unclear. In this study, we aim to examine the causal relationship between genetically predicted dietary composition and the risk and severity of MS using two-sample Mendelian randomization.

Method

Genetic instruments for 30 different dietary compositions were extracted from large-scale genome-wide association studies (GWAS), mainly from the UK Biobank dataset. The GWAS data for MS risk and severity were obtained from the International Multiple Sclerosis Genetics Consortium. The primary analysis employed either the inverse variance weighted method or the Wald ratio method to evaluate the causal association. Several sensitivity analyses were also performed.

Results

Genetically predicted higher pork intake was causally associated with an increased risk of MS (odds ratio [OR] = 6.76; p = 0.005), while genetically driven higher cereal intake (OR = 0.43, p = 0.016), vitamin C supplement (OR < 0.01; p = 4.34 × 10-5), folic acid supplement (OR < 0.01; p = 4.91 × 10-71), and fish oil supplement (OR = 0.04; p = 0.017) were causally linked to a decreased risk of MS. In addition, genetically predicted higher alcoholic intake (OR = 1.17; p = 0.041) was causally associated with an increase in MS severity, while folic acid supplement (OR < 0.01; p = 0.015) was causally linked to a decrease in MS severity.

Interpretation

This study found that increased consumption of cereal, vitamin C, folic acid, and fish oil, coupled with reduced pork and alcohol intake, may potentially decrease the risk and severity of MS. These findings inform the development of dietary-based strategies for MS prevention and treatment.

Impact of tobacco smoking on disease-specific outcomes in common neurological disorders: A scoping review

Although the association of smoking with the risk of incident neurological disorders is well established, less is known about the impact of smoking and smoking cessation on outcomes of these conditions. The objective of this scoping review was to synthesize what is known about the impact of smoking and smoking cessation on disease-specific outcomes for seven common neurological disorders. We included 67 studies on the association of smoking and smoking cessation on disease-specific outcomes. For multiple sclerosis, smoking was associated with greater clinical and radiological disease progression, relapses, risk for disease-related death, cognitive decline, and mood symptoms, in addition to reduced treatment effectiveness. For stroke and transient ischemic attack, smoking was associated with greater rates of stroke recurrence, post-stroke cardiovascular outcomes, post-stroke mortality, post-stroke cognitive impairment, and functional impairment. In patients with cognitive impairment and dementia, smoking was associated with faster cognitive decline, and smoking was also associated with greater cognitive decline in Parkinson's disease, but not motor symptom worsening. Patients with amyotrophic lateral sclerosis who smoked faced increased mortality. Last, in patients with cluster headache, smoking was associated with more frequent and longer cluster attack periods. Conversely, for multiple sclerosis and stroke, smoking cessation was associated with improved disease-specific outcomes. In summary, whereas smoking is detrimentally associated with disease-specific outcomes in common neurological conditions, there is growing evidence that smoking cessation may improve outcomes. Effective smoking cessation interventions should be leveraged in the management of common neurological disorders to improve patient outcomes.

Impaired lung function in multiple sclerosis: a single-center observational study in 371 persons

INTRODUCTION

Abnormal lung function in people with multiple sclerosis (PwMS) could be considered as the result of muscle weakness or MS-specific structural central nervous system (CNS) abnormalities as a precipitant factor for the worsening of motor impairment or cognitive symptoms.

METHODS

This is a cross-sectional observational study in PwMS. Forced spirometry was conducted, and normative metrics of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the relation FEV1/FVC were calculated. Qualitative and quantitative brain magnetic resonance imaging (MRI) examinations were carried out.

RESULTS

A total of 371 PwMS were included in the study. Of those, 196 (53%) had RRMS, 92 (25%) SPMS, and 83 (22%) PPMS. Low FVC and FEV1 was present in 16 (8%), 16 (19%), and 23 (25%) of the patients in the RRMS, PPMS, and SPMS, respectively. PwMS with T2-FLAIR lesions involving the corpus callosum (CC) had a significantly higher frequency of abnormally low FVC and FEV1 (OR 3.62; 95% CI 1.33-9.83; p = 0.012) than patients without lesions in that region. This association remained significant in the RRMS group (OR 10.1; 95% CI 1.3-67.8; p 0.031) when the model excluded PPMS and SPMS. According to our study, for every increase of 1 z score of FVC, we observed an increase of 0.25 cm3 of hippocampal volume (β 0.25; 95% CI 0.03-0.47; p 0.023) and 0.43 cm3 of left hippocampus volume (β 0.43; 95% CI 0.16-0.71; p 0.002).

CONCLUSIONS

We observed an incremental prevalence of abnormally low pulmonary function tests that parallels a sequence from more early relapsing courses to long-standing progressive courses (RRMS to PPMS or SPMS).

The Importance of Managing Modifiable Comorbidities in People with Multiple Sclerosis: A Narrative Review

Multiple sclerosis (MS) is a chronic, inflammatory, degenerative demyelinating disease of the central nervous system (CNS) of unknown etiology that affects individuals in their early adulthood. In the last decade, life expectancy for people with MS (PwMS) has almost equaled that of the general population. This demographic shift necessitates a heightened awareness of comorbidities, especially the ones that can be prevented and modified, that can significantly impact disease progression and management. Vascular comorbidities are of particular interest as they are mostly modifiable health states, along with voluntary behaviors, such as smoking and alcohol consumption, commonly observed among individuals with MS. Vascular risk factors have also been implicated in the etiology of cerebral small vessel disease. Furthermore, differentiating between vascular and MS lesion load poses a significant challenge due to overlapping clinical and radiological features. This review describes the current evidence regarding the range of preventable and modifiable comorbidities and risk factors and their implications for PwMS.

The effects of different types of smoking on recovery from attack in hospitalized multiple sclerosis patients

BACKGROUND

Several studies demonstrated the association between tobacco smoking and higher risk and increased progression of multiple sclerosis (MS). Data about the effect of smoking during the recovery from MS attacks is limited. Furthermore, different types of tobacco exposures such as water pipe and passive smoking are not well assessed separately. So this study evaluated the effect of different types of smokes, cigarette and water pipe as well as passive smoking on the function recovery of relapsing-remitting MS (RRMS) attacks METHODS: This cohort study evaluated the adult patients with RRMS and Expanded Disability Status Scale (EDSS) < 5 in the attack phase. Patients were divided into two groups: smokers and non-smokers. The smokers included those who use cigarette, water pipe as well as passive smokers as subgroups for more analyses later. EDSS was monitored after relapse and two months after relapse. Change of EDSS considered as the criteria for functional recovery. The correlation between the amount of consumption and disability level was assessed among smokers by Pearson's correlation test. While, the difference of EDSS between smoker and non-smoker were assessed by Independent samples T-test.

RESULTS

142 patients were evaluated. 79 (55.6%) were smokers (43% male) while 63 (44.4%) were non-smokers (36.5% male). There was a statistically significant difference in change of EDSS between smoker and non-smoker groups, which change of EDSS was higher in non-smoker (-2.62 ± 0.90 non-smoker vs. -1.75 ± 0.76 smoker, P < 0.001). Also, only there was a significantly lesser decline in EDSS after two months in the cigarette smokers in subgroups analyses (P < 0.001). A correlation analysis revealed a significant positive correlation between the number per day of cigarette smoking and EDSS after relapse (r = 0.3, P = 0.03) and a significant positive correlation between minutes per month of smoking of water pipe and EDSS two months after relapse (r = ‎0.6‎‎, P > 0.001).

CONCLUSION

Tobacco smoking especially cigarette smoking is associated with a negative effect on recovery from the attack in patients with RRMS.

Potentially modifiable associates of anxiety in people with multiple sclerosis: a systematic review

PURPOSE

A high percentage of people with multiple sclerosis (PwMS) experience anxiety, which can negatively impact quality of life. Despite this, anxiety in PwMS remains under researched. This review aims to identify associates with anxiety in PwMS that are amenable to change, with a view to informing the development of interventions in the area.

MATERIALS AND METHODS

The following databases were searched for studies investigating anxiety in PwMS from 2015 to 2021: PsycINFO, PubMed, EMBASE, Web of Science. The search consisted of keywords relating to MS and fear, anxiety or worry. Once screening was completed by two reviewers, a narrative synthesis was used to analyze the data, with the MMAT used for quality appraisal.

RESULTS

Of the 3117 unique abstracts screened, 39 studies met the criteria for inclusion. Evidence was found linking anxiety in PwMS to several modifiable factors broadly categorized as either psychological, social or lifestyle factors. Perceptions of self and one's ability to cope/adjust to MS emerged as important psychological factors. Physical activity and social support from friends were also linked with improved anxiety outcomes.

CONCLUSIONS

Anxiety in PwMS is linked to a number of modifiable factors. Findings may help inform the development of rehabilitation interventions to decrease anxiety in MS.Implications for rehabilitationThis review highlights interventions which have successfully lowered anxiety in people with MS (PwMS); however, there is a clear need for the development of further interventions which target the pathologically specific concerns surrounding anxiety in this population.We show how a number of factors amenable to change associate with anxiety, suggesting that these factors may be appropriate targets for anxiety interventions in PwMS.Enhancing physical activity and self-efficacy are important means in which healthcare professionals can reduce anxiety in MS.Identifying ways of encouraging positive coping and increasing social support are further targets for improving comorbid anxiety in PwMS.Focusing on the modifiable factors highlighted here offers considerable potential for enhancing psychological wellbeing in this group.

Timely intervention, monitoring and education MATTERS in MS (TIME MATTERS in MS): Development of a globally applicable quality improvement tool

Background

Previously, consensus MS care standards were defined by MS specialist neurologists from 19 countries. We developed, piloted and refined an Excel-based quality improvement tool to enable MS services to benchmark against these standards. Here, we examine the refined tool.

Objective

To determine the applicability of the quality improvement tool in different healthcare settings.

Methods

MS centres across the globe were invited to pilot the quality improvement tool by coding the medical records of 36 adults with MS. We invited feedback on user friendliness, quality improvement tool usefulness and relevance of data collected.

Results

Seventeen centres from 14 countries participated; 14 completed the post-service evaluation survey. Over 50% of responders rated the tool ‘very easy’ or ‘easy’ to use and ‘very relevant’ to their service. Almost 85% of responders (11/13) planned to introduce changes to their service, including improvements in documentation, communication, interactions with colleagues and referrals; 85% would use a future shorter version of the tool.

Conclusions

The quality improvement tool can enable MS centres globally to benchmark their services. Widespread uptake of a shorter tool may help MS centres to work towards achieving consensus standards for brain health-focused care. Incorporation into routine clinical practice would drive adoption.

Alcohol consumption is associated with excessive risk of multiple sclerosis: a meta-analysis observational study

BACKGROUND

There have been inconsistent results regarding the association between alcohol intake and susceptibility to multiple sclerosis.

OBJECTIVE

To assess the potential role of alcohol intake regarding the risk of multiple sclerosis by using a meta-analytic approach.

DESIGN AND SETTING

Observational meta-analysis study conducted in a hospital in China.

METHODS

The electronic databases of PubMed, EMBASE and the Cochrane library were systematically searched for eligible studies from their inception up to January 2020. The summary odds ratio (OR) with 95% confidence interval (CI) was applied to assess the association between alcohol intake and multiple sclerosis, using a random-effects model.

RESULTS

One prospective cohort study and eight case-control studies involving a total of 211,396 subjects and 10,407 cases of multiple sclerosis were selected for the final meta-analysis. From the pooled data, no significant association between alcohol intake and multiple sclerosis risk was found (OR: 0.94; 95% CI: 0.73-1.22; P = 0.668), and this conclusion was judged to be robust. Subgroup analysis found that intake of beer was associated with an increased risk of multiple sclerosis (OR: 1.58; 95% CI: 1.12-2.23; P = 0.010).

CONCLUSION

This study found that beer intake could cause an excess risk of multiple sclerosis. Further large-scale prospective studies should be conducted to verify this conclusion.

Association of Body Mass Index in Adolescence and Young Adulthood and Long-term Risk of Multiple Sclerosis: A Population-Based Study

BACKGROUND AND OBJECTIVES

To prospectively investigate the long-term relationship between body mass index (BMI) in adolescents and young adults and risk for multiple sclerosis (MS) at the population level.

METHODS

We used data from the population-based compulsory Norwegian tuberculosis screening program during 1963 to 1975, including objectively measured height and weight from ≈85% of all eligible citizens. This was combined with data from the Norwegian MS registry and biobank up to November 2020. BMI was standardized according to age and sex, and risk for MS was calculated with Cox proportional hazard models.

RESULTS

During 30,829,506 years of follow-up, we found 1,409 cases of MS among 648,734 participants in eligible age groups (14-34 years). Overall, obesity was associated with increased MS risk (hazard ratio [HR] 1.53 [95% confidence interval (CI) 1.25-1.88]), and the risk was similar in men (HR 1.4 [95% CI 0.95-2.06] and women (HR 1.59 [95% CI 1.25-2.02]). Risk was highest for the youngest age groups (age 14-16: HR 1.73 [95% CI 1.19-2.53]; 17-19: HR 1.61 [95% CI 1.08-2.39]; 20-24: HR 1.56 [95% CI 1.04-2.36]) and was no longer present for those >30 years of age.

DISCUSSION

High BMI in individuals 14 to 24 years of age was associated with increased MS risk later in life in both male and female individuals.

Development and Cross-Validation of a Simple Model to Estimate Percent Body Fat in Persons with Multiple Sclerosis

Background

Persons with multiple sclerosis (MS) have higher body composition variability compared with the general population. Monitoring body composition requires accurate methods for estimating percent body fat (%BF). We developed and cross-validated an equation for estimating %BF from body mass index (BMI) and sex in persons with MS.

Methods

Seventy-seven adults with MS represented the sample for the equation development. A separate sample of 33 adults with MS permitted the equation cross-validation. Dual-energy x-ray absorptiometry (DXA) provided the criterion %BF.

Results

The model including BMI and sex (mean ± SD age: women, 49.2 ± 8.8 years; men, 48.6 ± 9.8 years) had high predictive ability for estimating %BF (P < .001, R² = 0.77, standard error of estimate = 4.06%). Age, MS type, Patient-Determined Disease Steps score, and MS duration did not improve the model. The equation was %BF = 3.168 + (0.895 × BMI) - (10.191 × sex); sex, 0 = woman; 1 = man. The equation was cross-validated in the separate sample (age: women, 48.4 ± 9.4 years; men, 43.8 ± 15.4 years) based on high accuracy as indicated by strong association (r = 0.89, P < .001), nonsignificant difference (mean: 0.2%, P > .05), small absolute error (mean: 2.7%), root mean square error (3.5%), and small differences and no bias in Bland-Altman analysis (mean difference: 0.2%, 95% CI: -6.98 to 6.55, r_s = -0.07, P = .702) between DXA-determined and equation-estimated %BF.

Conclusions

Health care providers can use this developed and cross-validated equation for estimating adiposity in persons with MS when DXA is unavailable.

The increased risk of multiple sclerosis associated with HLA-DRB1*15:01 and smoking is modified by alcohol consumption

Previous studies have observed an inverse association between alcohol consumption and multiple sclerosis (MS) risk. We aimed to investigate possible interactions between alcohol consumption, MS-associated human leukocyte antigen (HLA) genes and smoking regarding MS risk. We used a Swedish population-based case-control study (2059 incident cases, 2887 controls) matched by age, sex, and residential area. Subjects with different genotypes and alcohol consumption habits were compared regarding MS risk, by calculating odds ratios with 95% confidence intervals using logistic regression models. Interaction on the additive scale between non-drinking and both genotype and smoking were assessed by calculating the attributable proportion due to interaction (AP). There was a dose-dependent inverse association between alcohol consumption and MS risk (p for trend < 0.0001). A potentiating effect was observed between non-drinking and presence of DRB1*15:01 (AP 0.3, 95% CI 0.2-0.5) which was of similar magnitude irrespective of smoking habits. Non-drinking also interacted with smoking to increase MS risk (AP 0.2, 95% CI 0.06-0.4). Non-drinking interacts with DRB1*15:01 and smoking to increase the risk of MS. Better understanding of the mechanisms behind our findings may help to define ways to achieve protection against MS by other means than alcohol consumption.

Genetic, Environmental and Lifestyle Determinants of Accelerated Telomere Attrition as Contributors to Risk and Severity of Multiple Sclerosis

Telomeres are protective structures at the ends of linear chromosomes. Shortened telomere lengths (TL) are an indicator of premature biological aging and have been associated with a wide spectrum of disorders, including multiple sclerosis (MS). MS is a chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system. The exact cause of MS is still unclear. Here, we provide an overview of genetic, environmental and lifestyle factors that have been described to influence TL and to contribute to susceptibility to MS and possibly disease severity. We show that several early-life factors are linked to both reduced TL and higher risk of MS, e.g., adolescent obesity, lack of physical activity, smoking and vitamin D deficiency. This suggests that the mechanisms underlying the disease are connected to cellular aging and senescence promoted by increased inflammation and oxidative stress. Additional prospective research is needed to clearly define the extent to which lifestyle changes can slow down disease progression and prevent accelerated telomere loss in individual patients. It is also important to further elucidate the interactions between shared determinants of TL and MS. In future, cell type-specific studies and advanced TL measurement methods could help to better understand how telomeres may be causally involved in disease processes and to uncover novel opportunities for improved biomarkers and therapeutic interventions in MS.

Role of environmental factors in multiple sclerosis

INTRODUCTION

Environmental factors play a significant role in the pathogenesis and progression of multiple sclerosis (MS), either acting alone or by interacting with other environmental or genetic factors. This cumulative exposure to external risk factors is highly complex and highly variable between individuals.

AREAS COVERED

We narratively review the current evidence on the role of environment-specific risk factors in MS onset and progression, as well as the effect of gene-environment interactions and the timing of exposure We have reviewed the latest literature, by Ovid Medline, retrieving the most recently published systematic reviews and/or meta-analyses and more recent studies not previously included in meta-analyses or systematic reviews.

EXPERT OPINION

There is some good evidence supporting the impact of some environmental risk factors in increasing the risk of developing MS. Tobacco smoking, low vitamin D levels and/or low sun exposure, Epstein Barr Virus (EBV) seropositivity and a history of infectious mononucleosis may increase the risk of developing MS. Additionally, there is some evidence that gene-smoking, gene-EBV, and smoking-EBV interactions additively affect the risk of MS onset. However, the evidence for a role of other environmental factors in MS progression is limited. Finally, there is some evidence that tobacco smoking, insufficient vitamin D levels and/or sun exposure have impacts on MS phenotypes and various markers of disease activity including relapse, disability progression and MRI findings. Clearly the effect of environmental factors on MS disease course is an area that requires significantly more research.

Biopsychosocial implications of living with multiple sclerosis: a qualitative study using interpretative phenomenological analysis

BACKGROUND

Multiple sclerosis (MS) is estimated to affect 2.8 million people worldwide, with increasing prevalence in all world regions (Walton et al). While there is no cure for MS, medication and lifestyle modifications can slow disease progression and enhance patients' quality of life. The biopsychosocial model of health recognises important interactions among biological, psychological and social factors in illness, including those relating to illness management, which contribute to the experience of those diagnosed with MS.

OBJECTIVE

This qualitative, idiographic study aimed to explore the lived experiences of patients in the United Arab Emirates (UAE) diagnosed with S.

METHODS

Semistructured interviews were conducted with a purposive sample of eight patients with MS ranging in age from 25 to 56 years. All participants were residing in the UAE at the time of data collection. Interpretative phenomenological analysis was used to analyse the data.

RESULTS

Three superordinate themes were identified from patients' candid accounts of their lives with MS, highlighting issues of illness management, acceptance and gratitude, and adaptive coping. These themes broadly illustrate biological, psychological and social aspects of patients' MS experiences.

CONCLUSION

The study emphasised the importance of adopting the biopsychosocial model to treat and manage MS. Additionally, it highlights the need for routine assessment and early, multidimensional approach with multidisciplinary team efforts to improve patients' quality of life.

The effect of the Australian bushfires and the COVID-19 pandemic on health behaviours in people with multiple sclerosis

BACKGROUND

Crises and disasters disproportionally impact people with chronic health conditions such as multiple sclerosis (MS).

OBJECTIVE

To assess the impact of the COVID-19 pandemic and the Australian Black Summer Bushfires on health behaviours in people with MS.

METHODS

People with MS, carers, healthcare and advocacy professionals were recruited online between May-July 2020 for an online survey and telephone interviews.

RESULTS

Survey items relating to health behaviours were completed by 113 people with MS, and 18 people with MS, 4 MS advocates, 5 healthcare professionals, and 2 carers were interviewed. The bushfires affected 34.5% and the pandemic affected 74.3% of survey participants with MS. The pandemic and bushfires caused a decrease in physical activity in 53.8% and 55.3% of participants respectively, as well as increases in unhealthy eating (43.6% and 24.3% respectively) and alcohol consumption (35.4% and 10.5% respectively), and a decrease in typical sleeping patterns (40.5% and 39.5% respectively). Conversely, 27.5% of participants reported an increase in physical activity during the pandemic. Interview data detailed the circumstances and motivations for changes in health behaviours, as well as consequences, including reduced mobility, fitness, mood disturbances, and weight gain.

CONCLUSION

There is a need to increase support and health promotion for people with MS to maintain or initiate positive health behaviours, especially in times of adversity.

Predicting disability worsening in relapsing and progressive multiple sclerosis

PURPOSE OF REVIEW

Multiple sclerosis (MS) is a clinically heterogeneous disease, which complicates expectant management as well as treatment decisions. This review provides an overview of both well established and emerging predictors of disability worsening, including clinical factors, imaging factors, biomarkers and treatment strategies.

RECENT FINDINGS

In addition to well known clinical predictors (age, male sex, clinical presentation, relapse behaviour), smoking, obesity, vascular and psychiatric comorbidities are associated with subsequent disability worsening in persons with MS. A number of imaging features are predictive of disability worsening and are present to varying degrees in relapsing and progressive forms of MS. These include brain volumes, spinal cord atrophy, lesion volumes and optical coherence tomography features. Cerebrospinal and more recently blood biomarkers including neurofilament light show promise as more easily attainable biomarkers of future disability accumulation. Importantly, recent observational studies suggest that initiation of early-intensive therapy, as opposed to escalation based on breakthrough disease, is associated with decreased accumulation of disability overall, although randomized controlled trials investigating this question are underway.

SUMMARY

Understanding risk factors associated with disability progression can help to both counsel patients and enhance the clinician's availability to provide evidence-based treatment recommendations.

Association of body mass index with longitudinal rates of retinal atrophy in multiple sclerosis

BACKGROUND

Studies evaluating associations between body mass index (BMI) and optical coherence tomography (OCT) measures in multiple sclerosis (MS) are lacking.

OBJECTIVE

To assess whether elevated BMI is associated with accelerated retinal atrophy.

METHODS

In this observational study, 513 MS patients were followed with serial spectral-domain OCT for a median of 4.4 years. Participants were categorized as normal weight (BMI: 18.5-24.9 kg/m²), overweight (BMI: 25-29.9 kg/m²), and obese (BMI: ⩾30 kg/m²). Participants with diabetes mellitus or uncontrolled hypertension and eyes with optic neuritis (ON) ⩽6 months prior to baseline OCT or during follow-up were excluded. Statistical analyses were performed with mixed-effects linear regression.

RESULTS

Obese patients (n = 146) exhibited accelerated rates of ganglion cell + inner plexiform layer (GCIPL) atrophy relative to normal weight patients (n = 214; -0.57%/year (95% confidence interval (CI): -0.65% to -0.48%) versus -0.42%/year (95% CI: -0.49% to -0.35%); p = 0.012). GCIPL atrophy rate did not differ between overweight (n = 153) and normal weight patients (-0.47%/year vs -0.42%/year; p = 0.41). Each 1 kg/m² higher BMI was associated with accelerated GCIPL (-0.011%/year; 95% CI: -0.019% to -0.004%; p = 0.003) atrophy. Multivariable analyses accounting for age, sex, race, MS subtype, and ON history did not alter the above findings.

CONCLUSIONS

Elevated BMI, in the absence of overt metabolic comorbidities, may be associated with accelerated GCIPL atrophy. Obesity, a modifiable risk factor, may be associated with accelerated neurodegeneration in MS.

Predictors of Multiple Sclerosis Severity Score in Patients with Multiple Sclerosis

Background

Multiple sclerosis (MS) is a demyelinating autoimmune disorder. Several factors have been shown to associate with MS clinical severity. The influence of different lifestyle factors on MS clinical severity as assessed by the Multiple Sclerosis Severity Score (MSSS) was investigated.

Methods

A questionnaire was administered to 128 Kuwaiti MS patients to assess the association of smoking, nutritional supplement use, food allergy, physical activity (PA), and educational level with MSSS. A multiple linear regression model was used to test for associations. Regression model results were adjusted for sex, history of blood transfusion, age at MS onset, and marital status.

Results

Smoking status, passive smoking, and food allergy are not associated with MSSS. Patients with MS with a college education and graduate/professional degrees score, on average, 2.56 lower on the MSSS compared with those with less than a high school education (β= -2.22, P = .045; and β = -2.90, P = .048, respectively). Patients who perform PA score, on average, 2.32 lower on the MSSS compared with those with no PA (moderate exercise, P = .003; rigorous exercise, P = .001), and PA correlated significantly with MSSS outcomes (r² = 0.452, P < .001).

Conclusions

Educational level and PA are significantly associated with reduced MSSS, and both contribute to a less severe MS clinical course. Current MS management protocols should consider lifestyle changes to improve the quality of life of patients with MS.

Body Mass Index in Multiple Sclerosis modulates ceramide-induced DNA methylation and disease course

BACKGROUND

Multiple Sclerosis (MS) results from genetic predisposition and environmental variables, including elevated Body Mass Index (BMI) in early life. This study addresses the effect of BMI on the epigenome of monocytes and disease course in MS.

METHODS

Fifty-four therapy-naive Relapsing Remitting (RR) MS patients with high and normal BMI received clinical and MRI evaluation. Blood samples were immunophenotyped, and processed for unbiased plasma lipidomic profiling and genome-wide DNA methylation analysis of circulating monocytes. The main findings at baseline were validated in an independent cohort of 91 therapy-naïve RRMS patients. Disease course was evaluated by a two-year longitudinal follow up and mechanistic hypotheses tested in human cell cultures and in animal models of MS.

FINDINGS

Higher monocytic counts and plasma ceramides, and hypermethylation of genes involved in negative regulation of cell proliferation were detected in the high BMI group of MS patients compared to normal BMI. Ceramide treatment of monocytic cell cultures increased proliferation in a dose-dependent manner and was prevented by DNA methylation inhibitors. The high BMI group of MS patients showed a negative correlation between monocytic counts and brain volume. Those subjects at a two-year follow-up showed increased T1 lesion load, increased disease activity, and worsened clinical disability. Lastly, the relationship between body weight, monocytic infiltration, DNA methylation and disease course was validated in mouse models of MS.

INTERPRETATION

High BMI negatively impacts disease course in Multiple Sclerosis by modulating monocyte cell number through ceramide-induced DNA methylation of anti-proliferative genes. FUND: This work was supported by funds from the Friedman Brain Institute, NIH, and Multiple Sclerosis Society.

Oxygen Cost During Mobility Tasks and Its Relationship to Fatigue in Progressive Multiple Sclerosis

OBJECTIVE

To compare the oxygen costs of mobility tasks between individuals with progressive multiple sclerosis (MS) using walking aids and matched controls and to determine whether oxygen cost predicted fatigue.

DESIGN

Cross-sectional descriptive.

SETTING

A rehabilitation research laboratory.

PARTICIPANTS

A total of 14 adults with progressive MS (mean age ± SD [y], 54.07±8.46) using walking aids and 8 age- and sex-matched controls without MS (N=22).

INTERVENTIONS

Participants performed 5 mobility tasks (rolling in bed, lying to sitting, sitting to standing, walking, climbing steps) wearing a portable metabolic cart.

MAIN OUTCOME MEASURES

Oxygen consumption (V˙o₂) during mobility tasks, maximal V˙o₂ during graded maximal exercise test, perceived exertion, and task-induced fatigue were measured on a visual analog scale before and after mobility tasks.

RESULTS

People with progressive MS had significantly higher oxygen cost in all tasks compared to controls (P<.05): climbing steps (3.60 times more in MS), rolling in bed (3.53), walking (3.10), lying to sitting (2.50), and sitting to standing (1.82). There was a strong, positive correlation between task-induced fatigue and oxygen cost of walking, (ρ [13]=0.626, P=.022).

CONCLUSIONS

People with progressive MS used 2.81 times more energy on average for mobility tasks compared to controls. People with progressive MS experienced accumulation of oxygen cost, fatigue, and exertion when repeating tasks and higher oxygen cost during walking was related to greater perception of fatigue. Our findings suggest that rehabilitation interventions that increase endurance during functional tasks could help reduce fatigue in people with progressive MS who use walking aids.

The Impact of Lifetime Alcohol and Cigarette Smoking Loads on Multiple Sclerosis Severity

Background: The association between lifestyle factors and Multiple Sclerosis (MS) disease severity and progression has been investigated to a lesser extent compared with susceptibility to the disease. Objective: We aimed to assess the impact of lifetime alcohol and cigarette smoking load on MS severity. Methods: Design: a cross-sectional study. Three hundred fifty-one patients consecutively admitted to the Department of Neurology were asked to complete the "Questionnaire of Lifestyle" (part of the European Prospective Investigation into Cancer and Nutrition project). An estimation of the cumulative lifetime cigarette smoking and alcohol load was calculated as the weighted sum of the mean number of cigarettes smoked and standard alcoholic drinks consumed per day at different ages. The measure of exposure was expressed in terms of pack-year and drink-year. Disease severity was estimated by the Multiple Sclerosis Severity Score (MSSS). Logistic regression analyses were performed using MSSS (first tertile vs. third tertile) as the outcome. Results: The median MSSS was higher (3.2 vs. 2.3, p = 0.002) in ever- vs. never-smokers, but we did not find a difference between ever- and never-drinkers (2.7 vs. 2.8, p = ns). Ever-smokers were almost twice as likely to fall in the upper MSSS tertile than never-smokers. Ever-drinkers did not show a statistically significant association between alcohol intake and MS severity. The risk of falling in the worst MSSS tertile for smokers was 10.81 (2.0-58.48; p < 0.01) if they were never-drinkers, whereas it was only 1.65 (0.89-3.03, p = 0.11) if they were also drinkers. On the other side, the risk of falling in the worst MSSS tertile for drinkers did not change as much, whether they also were smokers (0.46; 0.13-1.65; p = 0.23) or not (1.49; 0.55-4.04, p = 0.43). Conclusions: Cigarette smoking, unlike alcohol consumption, is associated with MS severity. Alcohol consumption may attenuate the effect of smoking on disease severity, acting as an effect modifier. The biological background of this effect is unknown. The limitations of our study are mostly due to its cross-sectional design.

Health Outcomes and Lifestyle in a Sample of People With Multiple Sclerosis (HOLISM): Longitudinal and Validation Cohorts

Objective: To report the methodology and summary data of the Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) longitudinal and validation cohorts. We report (1) data on participation, socio-demographics, disease characteristics, medication use, modifiable lifestyle risk factor exposures, and health outcomes of the HOLISM longitudinal cohort 2.5-years post enrolment; (2) attrition at this 2.5-year wave; and (3) baseline characteristics of the associated HOLISM validation cohort. Methods: The HOLISM longitudinal study recruited people internationally with self-reported diagnosed multiple sclerosis (MS) through web 2.0 platforms and MS society newsletters. Participants, first recruited in 2012, were invited 2.5-years later to participate in a follow-up survey. At both time points, participants completed a comprehensive online questionnaire of socio-demographics, modifiable lifestyle exposures, and health outcomes using validated and researcher-designed tools. The same methodology was used to recruit a new sample: the HOLISM validation cohort. Characteristics were explored using summary measures. Results: Of 2,466 people with MS at baseline, 1,401 (56.8%) provided data at 2.5-year follow-up. Attrition was high, likely due to limited amount of contact information collected at baseline. Completion of the 2.5-year wave was associated with healthier lifestyle, and better health outcomes. Participants completing follow-up had diverse geographical location, were predominantly female, married, unemployed or retired. At 2.5-year follow-up, nearly 40% were overweight or obese, most were physically active, non-smokers, consumed little alcohol, used vitamin D/omega-3 supplements, and 42% reported current disease-modifying drug use. Thirty percentage of reported cane or gait disability, while 13% relied on major mobility supports (Patient Determined Disease Steps). Approximately half the respondents reported a comorbidity, 63% screened positive for clinically significant fatigue (Fatigue Severity Scale), and 22% screened positive for depression (Patient Health Questionnaire-9). The validation cohort's characteristics were mostly consistent with previously reported HOLISM baseline data. Conclusions: Exploring prospective associations of modifiable environmental/behavioral risk factors with health outcomes in this international longitudinal sample of people with MS will be beneficial to MS research. Impacts of attrition and selection bias will require consideration. The validation cohort provides opportunity for replication of previous findings, and also for temporal validation of predictive models derived from the HOLISM cohort.

International consensus on quality standards for brain health-focused care in multiple sclerosis

Background:

Time matters in multiple sclerosis (MS). Irreversible neural damage and cell loss occur from disease onset. The MS community has endorsed a management strategy of prompt diagnosis, timely intervention and regular proactive monitoring of treatment effectiveness and disease activity to improve outcomes in people with MS.

Objectives:

We sought to develop internationally applicable quality standards for timely, brain health–focused MS care.

Methods:

A panel of MS specialist neurologists participated in an iterative, online, modified Delphi process to define ‘core’, ‘achievable’ and ‘aspirational’ time frames reflecting minimum, good and high care standards, respectively. A multidisciplinary Reviewing Group (MS nurses, people with MS, allied healthcare professionals) provided insights ensuring recommendations reflected perspectives from multiple stakeholders.

Results:

Twenty-one MS neurologists from 19 countries reached consensus on most core (25/27), achievable (25/27) and aspirational (22/27) time frames at the end of five rounds. Agreed standards cover six aspects of the care pathway: symptom onset, referral and diagnosis, treatment decisions, lifestyle, disease monitoring and managing new symptoms.

Conclusion:

These quality standards for core, achievable and aspirational care provide MS teams with a three-level framework for service evaluation, benchmarking and improvement. They have the potential to produce a profound change in the care of people with MS.

The associated risk factors for underweight and overweight high school students in Cambodia

PURPOSE

Overweight and underweight are one of the leading risk factors for non-communicable diseases (NCDs), but little research on this area has been undertaken in Cambodia. Therefore, this study aimed to measure underweight and overweight and their associated risk behaviors among Cambodian high school students.

METHODS

3806 students (mean ag = 15.65 years, SD = 1.80, age range = 11-18 years) from the 2013 Cambodia-Global School-based Student Health Survey were used to yield representative samples of the Cambodian students. Body Mass Index (BMI) was assessed by students' self-reported height and weight. The substance use, depression, eating behaviors, suicidal ideation, and violence were examined as risk factors. The Chi-square and multinomial regressions were performed to assess the relationships between risk factors and BMI.

RESULTS

The prevalence of underweight was 47.4% (N = 1805, Male = 23.3%vs.24.1%) and overweight was 2.3% (N = 89, Male = 1.0%vs.1.3%). The BMI was significantly controlled by age, gender, and body height. Both underweight and overweight students were significantly vulnerable to substance use, feeling depressed, and violent behaviors. Of the risk factors, shortest sleep was prevalent for underweight students while feeling lonely and suicide attempts were the critical risks for overweight students. The daily fruit/vegetable consumption and physical activity were good preventive factors of both underweight and overweight epidemics.

CONCLUSIONS

The risk behaviors of students appear to be strongly associated with underweight and overweight. Interventions targeting these risk behaviors may have the potential to reduce risks. Meanwhile, the preventive strategies should focus on vulnerable students who have poor academic performance, mental health issues and a history of violent experiences.

The association between smoking and cardiometabolic risk among male adults with disabilities in Taiwan

BACKGROUND

Individuals with disabilities have health needs similar to the general population. Smoking and metabolic syndrome have emerged as major cardiovascular risks that contribute to systemic inflammation and mortality. However, few studies have focused on the association between smoking and cardiometabolic risks in adult men with disabilities.

AIMS

This study explored the prevalence of smoking and its association with cardiometabolic risk and associated factors among male adults with disabilities.

METHODS

This study was part of a nurse-led health-promotion program designed to examine the health needs in health programs for adults with disabilities. A community-based, cross-sectional study was conducted between July 2013-December 2014, in Chiayi County, Taiwan.

RESULTS

Of the total of 964 male participants enrolled in this study, 874 (90.7%) participants had complete data sets. The prevalence of cigarette smoking and metabolic syndrome were 42%, and 33.3%, respectively. More than half (62.7%) had high blood pressure and 43.5% had central obesity. Compared with non-smokers, smokers tended to engage in less frequent regular exercise ( p<0.001), eat fewer vegetables and fruit ( p<0.05), and drink less water ( p<0.05). After adjusting for potential confounding variables, multivariable logistic regression analysis showed that smoking was an independent factor for cardiometabolic risk.

CONCLUSION

The present findings show a high prevalence of cigarette smoking, unhealthy lifestyle, and cardiometabolic risk among adult men with disabilities. Clinicians and primary healthcare providers should reduce the consequences thereof by initiating innovative health promotion programs.