A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue

Nutritional interventional studies in patients with multiple sclerosis: a scoping review of the current clinical evidence

A good nutritional status appears to slow down disease progression and ameliorate symptoms' intensity in patients with multiple sclerosis (MS). Up to date, there are several interventional studies, which have explored the potential beneficial effects of specific dietary patterns as well as specific bioactive nutrients against disease progression and symptomatology of MS patients. This is a thorough, scoping review, which aims to critically summarize and scrutinize the currently available clinical evidence of the potential beneficial effects of nutritional interventional studies against MS progression and symptomatology. This review was conducted to systematically map the research done in this area, as well as to identify gaps in knowledge. For this purpose, we thoroughly explored the most accurate scientific web databases, e.g., PubMed, Scopus, Web of Science, and Google Scholar to achieve the most relevant clinical human studies applying effective and characteristic keywords. There are currently several dietary patterns and specific bioactive nutrients that show promising results by slowing down disease progression and by improving MS symptoms. However, there are also certain conflicting results, while most of the existing studies enrolled a small number of MS patients. Nutritional interventions may exert substantial protective effects against MS progression and symptomatology. However, large, long-term, randomized, double-blind, controlled clinical trials with a prospective design are strongly recommended to delineate whether such nutritional intervention may attenuate disease progression, and improve symptomatology in MS patients.

Microbiota, diet, and the gut-brain axis in multiple sclerosis and stroke

Intestinal microbiota can influence the phenotype and function of immune cell responses through the dissemination of bacterial antigens or metabolites. Diet is one of the major forces shaping the microbiota composition and metabolism, contributing to host homeostasis and disease susceptibility. Currently, nutrition is a complementary and alternative approach to the management of metabolic and neurological diseases and cancer. However, the knowledge of the exact mechanism of action of diet and microbiota on the gut-brain communication is only developing in recent years. Here, we reviewed the current knowledge on the effect of diet and microbiota on the gut-brain axis in patients with two different central nervous system diseases, multiple sclerosis and stroke. We have also highlighted the open questions in the field that we believe are important to address to gain a deeper understanding of the mechanisms by which diet can directly or indirectly affect the host via the microbiota. We think this will open up new approaches to the treatment, diagnosis, and monitoring of various diseases.

Effects of Exercise, Rehabilitation, and Nutritional Approaches on Body Composition and Bone Density in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

People with multiple sclerosis (pwMS) are affected by a wide range of disabilities, including a decrease in bone mineral density (BMD) and a worsening of body composition (BC), which negatively impact their quality of life quality. This study aims to analyze the effects of nonpharmacological interventions-in particular, physical activity, nutritional approaches, and rehabilitation-on BC and BMD in pwMS. This systematic review and meta-analysis was performed following the updated version of the PRISMA guidelines. In July 2022, five databases (MEDLINE, Embase, The Cochrane Library, Google Scholar, Web of Science) and gray literature were screened. Relevant articles published between 1 January 1990 and 1 September 2022 in any language were included. Outcomes of interest were anthropometric, BC measures, and BMD. The RoB 2.0 tool was used to assess the risk of bias. After duplicates elimination, 1120 records were screened, and 36 studies were included. A total of 25 articles were focused on physical activity and rehabilitation, 10 on nutrition, and 1 on multimodal intervention. One-third of the studies were judged to be at high risk of bias. The meta-analysis showed a high degree of heterogeneity due to the high variability in disease severity and intervention duration, intensity, frequency, and type. In general, no intervention showed consistent positive effects on BC. However, the most promising interventions seemed to be high-intensity training and ketogenic diets. Only a few studies considered BMD, and the results are inconsistent. Nevertheless, more studies are needed in order to confirm these results.

Palaeolithic diet score and risk of breast cancer among postmenopausal women overall and by hormone receptor and histologic subtypes

BACKGROUND

The Palaeolithic diet (PD) has gained popularity globally. There is emerging evidence of its putative health benefits as short-term effects on chronic diseases have been reported. We evaluated the association between long-term adherence to the PD and breast cancer (BC) risk among postmenopausal women.

METHODS

65,574 women from the Etude Epidémiologique auprès de femmes de la Mutuelle Générale de l'Education Nationale (E3N) cohort were followed from 1993 to 2014. Incident BC cases were identified and validated. The PD score was calculated using dietary intake self-reported at baseline (1993) and follow-up (2005) or baseline only if censored before follow-up. Multivariable Cox proportional hazards regression models were used to estimate BC hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Over a mean follow-up of 20 years, 3968 incident BC cases occurred. An increase of 1 standard deviation in the PD score was associated with an 8% lower BC risk, fully-adjusted model: HR1-SD 0.92, 95% CI; 0.89, 0.95. Compared to women with low adherence to the PD, women with high adherence had a 17% lower BC risk, HRQ5 vs Q1 0.83, 95% CI; 0.75, 0.92, Ptrend < 0.01. When considering BC subtypes, we observed the same pattern of association (Pheterogeneity > 0.10 for all).

CONCLUSIONS

High adherence to a PD characterised by fruit, vegetables, nuts, fish, and lean meat and limited in dairy, grains, legumes, refined sugar, and alcohol was associated with a lower BC risk. The lack of heterogeneity according to BC subtypes could indicate the involvement of non-hormonal mechanisms. The protocol is registered at clinicaltrials.gov as NCT03285230.

REGISTRY

The protocol is registered at clinicaltrials.gov as NCT03285230.

Overview of diet and autoimmune demyelinating optic neuritis: a narrative review

This review summarizes the cellular and molecular underpinnings of autoimmune demyelinating optic neuritis (ADON), a common sequela of multiple sclerosis and other demyelinating diseases. We further present nutritional interventions tested for people with multiple sclerosis focusing on strategies that have shown efficacy or associations with disease course and clinical outcomes. We then close by discuss the potential dietary guidance for preventing and/or ameliorating ADON.

Dietary protection against the visual and motor deficits induced by experimental autoimmune encephalomyelitis

Introduction

Five to eight percent of the world population currently suffers from at least one autoimmune disorder. Despite multiple immune modulatory therapies for autoimmune demyelinating diseases of the central nervous system, these treatments can be limiting for subsets of patients due to adverse effects and expense. To circumvent these barriers, we investigated a nutritional intervention in mice undergoing experimental autoimmune encephalomyelitis (EAE), a model of autoimmune-mediated demyelination that induces visual and motor pathologies similar to those experienced by people with multiple sclerosis (MS).

Methods

EAE was induced in female and male mice and the impact of limiting dietary carbohydrates by feeding a ketogenic diet (KD) enriched in medium chain triglycerides (MCTs), alpha-linolenic acid (an omega-3 fatty acid), and fiber was evaluated in both a preventive regimen (prior to immunization with MOG antigen) and an interventional regimen (following the onset of symptoms). Motor scores were assigned daily and visual acuity was measured using optokinetic tracking. Immunohistochemical analyses of optic nerves were done to assess inflammatory infiltrates and myelination status. Fatty acid and cytokine profiling from blood were performed to evaluate systemic inflammatory status.

Results

The KD was efficacious when fed as a preventive regimen as well as when initiated as an interventional regimen following symptom onset. The KD minimally impacted body weight during the experimental time course, increased circulating ketones, prevented motor and ocular deficits, preserved myelination of the optic nerve, and reduced infiltration of immune cells to optic nerves. The KD also increased anti-inflammatory-associated omega-3 fatty acids in the plasma and reduced select cytokines in the circulation associated with EAE-mediated pathological inflammation.

Discussion

In light of ongoing clinical trials using dietary strategies to treat people with MS, these findings support that a KD enriched in MCTs, omega-3 fatty acids, and fiber promotes a systemic anti-inflammatory milieu and ameliorates autoimmune-induced demyelinating visual and motor deficits.

The Wahls Behavior Change Model for Complex Chronic Diseases: A Clinician's Guide

Behavior change models are used to understand and intervene on health-related behaviors and outcomes. However, there is a gap in the literature regarding how to create and maintain behavior change in patients with complex chronic diseases such as Multiple Sclerosis (MS). To address this gap, the Wahls Behavior ChangeTM Model (WBCM) (The trademark applies to subsequent mention of the model.) was developed based on existing behavior change theory, empirical evidence, and extensive clinical experience caring for patients with complex chronic diseases. A patient-centered, comprehensive, and multimodal approach, this model provides a framework for understanding and implementing lifestyle behavior change. The overall goals of this paper are to: (1) review existing behavior change theories; (2) introduce the WBCM, including the model's 11 Principles for behavior change in patients with complex chronic diseases; and (3) share how providers can be trained to implement the WBCM. The WBCM can potentially improve short- and longer-term function and quality of life outcomes for people with complex chronic diseases.

Involvement of the Intestinal Microbiota in the Appearance of Multiple Sclerosis: Aloe vera and Citrus bergamia as Potential Candidates for Intestinal Health

Multiple sclerosis (MS) is a neurological and inflammatory autoimmune disease of the Central Nervous System in which selective activation of T and B lymphocytes prompts a reaction against myelin, inducing demyelination and axonal loss. Although MS is recognized to be an autoimmune pathology, the specific causes are many; thus, to date, it has been considered a disorder resulting from environmental factors in genetically susceptible individuals. Among the environmental factors hypothetically involved in MS, nutrition seems to be well related, although the role of nutritional factors is still unclear. The gut of mammals is home to a bacterial community of about 2000 species known as the “microbiota”, whose composition changes throughout the life of each individual. There are five bacterial phylas that make up the microbiota in healthy adults: Firmicutes (79.4%), Bacteroidetes (16.9%), Actinobacteria (2.5%), Proteobacteria (1%) and Verrucomicrobia (0.1%). The diversity and abundance of microbial populations justifies a condition known as eubiosis. On the contrary, the state of dysbiosis refers to altered diversity and abundance of the microbiota. Many studies carried out in the last few years have demonstrated that there is a relationship between the intestinal microflora and the progression of multiple sclerosis. This correlation was also demonstrated by the discovery that patients with MS, treated with specific prebiotics and probiotics, have greatly increased bacterial diversity in the intestinal microbiota, which might be otherwise reduced or absent. In particular, natural extracts of Aloe vera and bergamot fruits, rich in polyphenols and with a high percentage of polysaccharides (mostly found in indigestible and fermentable fibers), appear to be potential candidates to re-equilibrate the gut microbiota in MS patients. The present review article aims to assess the pathophysiological mechanisms that reveal the role of the microbiota in the development of MS. In addition, the potential for supplementing patients undergoing early stages of MS with Aloe vera as well as bergamot fibers, on top of conventional drug treatments, is discussed.

The Feasibility of a Web-Based Educational Lifestyle Program for People With Multiple Sclerosis: A Randomized Controlled Trial

Background

Modifiable lifestyle factors are important to aid people with multiple sclerosis in the self-management of their disease. Current self-management programs are limited by their face-to-face mode of delivery but there is immense potential with the internet to deliver these programs effectively.

Objective

The aims of this study are to assess the feasibility of a digitalized educational lifestyle self-management program for people with MS.

Methods

In this randomized controlled trial, people with MS were randomly allocated to participate in a 6-week tailored web-based educational lifestyle program or 6-week generic standard-care educational course, and were blinded to their allocation. Participants were recruited through multiple sclerosis (MS) Societies in four countries: Australia, New Zealand, Canada, and the United States. The primary outcome was to assess acceptability of the program defined as percentage completion of all modules at 6-weeks post-course commencement. Secondary outcomes included evaluating participant responses to the follow-up survey across three domains: accessibility, learnability, and desirability.

Results

Thirty-five participants from Australia, Canada, New Zealand, and the US completed the baseline survey and were randomized. Four participants were deemed ineligible due to incomplete baseline data; therefore, nine out of 15 and eight out of 16 participants completed 100% of the course in the intervention and standard-care arm courses, respectively.

Conclusions

This study found that this web-based educational lifestyle program is a feasible means of delivering educational content to people with MS via the internet according to our a priori targets of >40% of participants in the intervention arm, and >25% in the control arm to completing 100% of the course. It is therefore appropriate to evaluate this intervention further in a large, randomized controlled trial.

Trial registration

This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ID: ACTRN12621000245897).

Italian translation and validation of fatigue symptoms and impacts questionnaire in relapsing multiple sclerosis (FSIQ-RMS)

BACKGROUND

Fatigue is a disabling symptom of multiple sclerosis (MS) and impacts on daily life. The Fatigue Symptoms and Impacts Questionnaire-Relapsing Multiple Sclerosis (FSIQ-RMS) is a new 20-item tool that investigates the aspects of fatigue in MS. It concerns motor, cognitive, social, and emotional aspects of fatigue. We aim at validating the Italian version of FSIQ-RMS in an Italian population of MS patients and demonstrate its reliability and construct validity.

METHODS

We included patients with diagnosis of MS, age between 18 and 70 years with ability to participate in a 90-min interview. Each patient completed the Italian version of FSIQ-RMS and Fatigue Severity Scale (FSS) at the same time. Construct validity was explored by the exploratory factor analysis; reliability was assessed with Cronbach's alpha; and test-retest stability was examined through intraclass correlation coefficient (ICC). Concurrent validity was calculated using Pearson's correlation.

RESULTS

We enrolled 171 patients (126 female and 45 male), 83% with relapsing MS (RMS), and 17% with secondary progressive MS (SPMS). Italian FSIQ-RMS showed a Cronbach's alpha of 0.92; ICC was 0.96. Pearson's correlation coefficient between FSIQ-RMS and FSS total score was statistically significant (p < 0.01); FSIQ-RMS inversely correlated also with BMI and positively with EDSS.

CONCLUSION

The Italian version of FSIQ-RMS has excellent psychometric properties and can be used in research and clinical setting to evaluate physical, cognitive, and social fatigue in both RMS and SPMS.

Multiple sclerosis and the microbiota

Multiple sclerosis (MS), a neurological autoimmune disorder, has recently been linked to neuro-inflammatory influences from the gut. In this review, we address the idea that evolutionary mismatches could affect the pathogenesis of MS via the gut microbiota. The evolution of symbiosis as well as the recent introduction of evolutionary mismatches is considered, and evidence regarding the impact of diet on the MS-associated microbiota is evaluated. Distinctive microbial community compositions associated with the gut microbiota of MS patients are difficult to identify, and substantial study-to-study variation and even larger variations between individual profiles of MS patients are observed. Furthermore, although some dietary changes impact the progression of MS, MS-associated features of microbiota were found to be not necessarily associated with diet per se. In addition, immune function in MS patients potentially drives changes in microbial composition directly, in at least some individuals. Finally, assessment of evolutionary histories of animals with their gut symbionts suggests that the impact of evolutionary mismatch on the microbiota is less concerning than mismatches affecting helminths and protists. These observations suggest that the benefits of an anti-inflammatory diet for patients with MS may not be mediated by the microbiota per se. Furthermore, any alteration of the microbiota found in association with MS may be an effect rather than a cause. This conclusion is consistent with other studies indicating that a loss of complex eukaryotic symbionts, including helminths and protists, is a pivotal evolutionary mismatch that potentiates the increased prevalence of autoimmunity within a population.

Sociodemographic and clinical characteristics of diet adherence and relationship with diet quality in an international cohort of people with multiple sclerosis

BACKGROUND

Diet has been associated with the onset and progression of multiple sclerosis (MS). Multiple diets, varying in recommendations, have been proposed as beneficial to people with MS. The characteristics of those who follow specific diet-programs and the relationships of these diet-programs with diet quality is under-explored.

METHODS

Data from the HOLISM study were analysed. Adherence to selected MS-specific diets (Ashton Embry Best Bet, McDougall, Overcoming MS (OMS), Palaeolithic, Swank, and Wahls Elimination) were each queried on 5-point Likert scales, and moderate (≥3/5) and rigorous (≥4/5) adherence defined. Sociodemographic and clinical characteristics of adherence were evaluated by log-binomial regression. Relationships of diet-program adherence with diet quality as measured by Diet Habits Questionnaire were assessed by linear and log-binomial regression, as appropriate, adjusted for age, sex, socioeconomic status (SES), education, and clinically significant fatigue.

RESULTS

Forty-nine percent of participants reported at least 12-month adherence to a diet-program for their MS. Of these, 31.3% rigorously adhered to OMS, 4.9% to Swank, 1.7% to Wahls, and <1.5% to other diet-programs. Only adherence to any diet-program, OMS, Wahls, and Swank, were quantitatively assessed. Females, and participants of lower-than-average SES and longer disease duration were less adherent to any diet-program for MS, as well as those with higher disability, more clinically significant fatigue, greater depression risk, and more comorbidities. Those with higher-than-average SES were more adherent, as were those with higher physical and mental quality of life. Similar relationships were seen for OMS diet-program adherence. Adherence to Wahls diet-program was higher among those with progressive MS types and longer disease duration. No associations were found for adherence to Swank diet-program. Overall diet quality was higher among participants following any diet-program, particularly OMS and Swank, but not Wahls.

CONCLUSION

Greater adherence to MS specific diets was associated with higher SES, and higher quality of life. Following any diet program was associated with higher overall diet quality, with those adhering to the OMS diet having the highest diet quality. These results may inform health professionals in providing guidance to patients regarding diet in MS.

Macular Xanthophylls and Markers of the Anterior Visual Pathway among Persons with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) can cause retinal thinning among persons with MS with optic neuritis (MS-ON). Macular xanthophylls are carotenoids that comprise the macular pigment, filtering blue light and countering photo-oxidation. However, macular xanthophyll status and its implications for markers of neuroaxonal degeneration have not been examined in MS.

OBJECTIVES

This study characterized differences in macular and serum xanthophylls, and retinal morphometry [retinal nerve fiber layer thickness at the macular (mRNFL) and optic disc (odRNFL) and total macular volume (TMV)] in individuals with MS and healthy controls (HC). Associations between macular pigment optical density (MPOD) and retinal morphometry were also examined.

METHODS

Adults aged 45-64 y (HC, n = 42; MS, n = 40) participated in a cross-sectional study. MPOD was measured via heterochromatic flicker photometry. Retinal morphometry was measured via optical coherence tomography (OCT). Serum carotenoids were quantified using HPLC. Dietary carotenoids were collected using 7-d records. One-factor ANOVA was conducted to determine group effects on macular, serum, and dietary carotenoids. Partial correlations examined the relations between MPOD, retinal morphometry, diet, and serum carotenoids.

RESULTS

Relative to HC, persons with MS-ON had lower MPOD (Cohen's d = 0.84, P = 0.014), lower odRNFL (Cohen's d = 2.16, P <0.001), lower mRNFL (Cohen's d = 0.57, P = 0.028), and lower TMV (Cohen's d = 0.95, P = 0.011). MS without ON (MS) had lower odRNFL (Cohen's d = 0.93, P = 0.001) than HC and lower serum lutein than MS-ON subjects (Cohen's d = 0.65, P = 0.014). Among MS, MPOD was positively correlated with odRNFL thickness (ρ = 0.43, P = 0.049) and TMV (ρ = 0.45, P = 0.039), whereas odRNFL was negatively correlated with serum lutein (ρ = -0.68, P = 0.016) and zeaxanthin (ρ = -0.62, P = 0.028).

CONCLUSIONS

Persons with MS-ON exhibited poorer xanthophyll status in the macula and serum. MPOD was associated with beneficial anatomical features in the MS group. These findings warrant confirmation with larger cohorts and prospective trials to evaluate xanthophyll effects on the anterior visual pathway in MS.

Self-Reported Diet and Health Outcomes of Participants of the CCSVI-Tracking Survey Study

Of the 1575 participants of the CCSVI-Tracking Survey, 475 patients recorded their quality of life and EDSS outcomes for at least 2 months. Self-reported use of complementary and conventional therapies included diet, use of drug therapy, symptoms, quality of life, and mobility. Analysis included comparing outcomes related to different diets within and between groups. Adherence to the MS diet was not associated with a greater quality of life, less disability, a lower Symptom Score, or faster walking speed compared to other diets. Alternately, the participants from the Mediterranean diet region as a whole (µ = 32.65 (SD = 11.37, SE_M = 2.37, p = 0.05) had a significantly greater QoL (µ = 60, p = 0.05) and a lower MS symptom score, µ = 32.65 (11.37), p = 0.0029. A decline of symptoms was observed in all diet groups over 3 months with the most dramatic decline observed in participants from the Eastern Mediterranean diet region. The main effect for the within-subjects factor was significant, F(3, 1056) = 55.95, p < 0.001, indicating that there were significant differences between the groups.

High Prudent diet factor score predicts lower relapse hazard in early multiple sclerosis

BACKGROUND

Dietary patterns and their association with subsequent clinical course have not been well studied in early multiple sclerosis (MS).

OBJECTIVES

To describe dietary patterns in people in 5 years following first clinical demyelination and assess associations with MS conversion and relapse.

METHODS

This study included baseline food frequency questionnaire dietary intake (entry to the Ausimmune Study) and 5-year follow-up; iterated principal factor analysis was applied. MS conversion and relapse risks were assessed by Cox proportional hazards models, adjusted for age, sex, study site, education, body mass index (BMI), smoking and omega-3 supplement use.

RESULTS

In cases with a first clinical diagnosis of central nervous system (CNS) demyelination, we identified three major dietary patterns, 'Prudent', 'High-Vegetable' and 'Mixed', explaining 43%, 37% and 24% of diet variance in dietary intake, respectively. Fruits, vegetables, fish, wholegrains and nuts loaded highly on the Prudent pattern, starchy vegetables and legumes on the High-Vegetable pattern, and meats and alcohol on the Mixed pattern. Diet factor scores were not associated with MS conversion risk. Those with baseline Prudent scores above the median had significantly lower relapse risk (adjusted hazard ratio = 0.54, 95% confidence interval (CI) 0.37, 0.81) with some evidence of a plateau effect.

CONCLUSION

Prudent diet factor score above the median was prospectively associated with lower relapse risk in the 5 years following the first clinical demyelinating event.

Eating Pattern and Nutritional Risks among People with Multiple Sclerosis Following a Modified Paleolithic Diet

Preliminary studies suggest that a modified Paleolithic diet may benefit symptoms of fatigue in progressive multiple sclerosis (MS). However, this diet restricts the consumption of eggs, dairy, and gluten-containing grains, which may increase the risk of micronutrient deficiencies. Therefore, we evaluated the nutritional safety of this diet among people with progressive MS. Three nonconsecutive 24-h dietary recalls were collected from (n = 19) progressive MS participants in the final months of a diet intervention study and analyzed using Nutrition Data System for Research (NDSR) software. Food group intake was calculated, and intake of micronutrients was evaluated and compared to individual recommendations using Nutrient Adequacy Ratios (NARs). Blood was drawn at baseline and the end of the study to evaluate biomarker changes. Mean intake of fruits and vegetables exceeded nine servings/day and most participants excluded food groups. The intake of all micronutrients from food were above 100% NAR except for vitamin D (29.6 ± 34.6%), choline (73.2 ± 27.2%), and calcium (60.3 ± 22.8%), and one participant (1/19) exceeded the Tolerable Upper Limit (UL) for zinc, one (1/19) for vitamin A, and 37% (7/19) exceeded the chronic disease risk reduction (CDRR) for sodium. When intake from supplements was included in the analysis, several individuals exceeded ULs for magnesium (5/19), zinc (2/19), sodium (7/19), and vitamins A (2/19), D (9/19), C (1/19), B₆ (3/19), and niacin (10/19). Serum values of vitamins D, B₁₂, K₁, K₂, and folate significantly increased compared to respective baseline values, while homocysteine and magnesium values were significantly lower at 12 months. Calcium and vitamin A serum levels did not change. This modified Paleolithic diet is associated with minimal nutritional risks. However, excessive intake from supplements may be of concern.

Scoping review of Paleolithic dietary patterns: a definition proposal

The Paleolithic diet (PaleoDiet) is an allegedly healthy dietary pattern inspired by the consumption of wild foods and animals assumed to be consumed in the Paleolithic era. Despite gaining popularity in the media, different operational definitions of this Paleolithic nutritional intake have been used in research. Our hypothesis is that specific components used to define the PaleoDiet may modulate the association of this diet with several health outcomes. We comprehensively reviewed currently applied PaleoDiet scores and suggested a new score based on the food composition of current PaleoDiet definitions and the theoretical food content of a staple dietary pattern in the Paleolithic age. In a PubMed search up to December 2019, fourteen different PaleoDiet definitions were found. We observed some common components of the PaleoDiet among these definitions although we also found high heterogeneity in the list of specific foods that should be encouraged or banned within the PaleoDiet. Most studies suggest that the PaleoDiet may have beneficial effects in the prevention of cardiometabolic diseases (type 2 diabetes, overweight/obesity, CVD and hyperlipidaemias) but the level of evidence is still weak because of the limited number of studies with a large sample size, hard outcomes instead of surrogate outcomes and long-term follow-up. Finally, we propose a new PaleoDiet score composed of eleven food items, based on a high consumption of fruits, nuts, vegetables, fish, eggs and unprocessed meats (lean meats); and a minimum content of dairy products, grains and cereals, and legumes and practical absence of processed (or ultra-processed) foods or culinary ingredients.

The effects of the Paleolithic Diet on obesity anthropometric measurements

Abstract Comparing the effects of Paleolithic Diet (PD) and of a Guidelines Substantiated Diet (GSD) on anthropometric indicators of obese individuals. Randomized clinical trial. Obese patients were divided into two groups based on dietary prescription: PD and GSD. These diets encompassed 82 and 73 patients, respectively, who were followed-up for 60 days. Anthropometric measurements were taken before the beginning of the trial, at the 30th day of it and at the end of the experimental period. At the 60th experimental day, there was 26.8% treatment abandonment by individuals in group PD and 19.2% by the ones in group GSD; there was not difference between groups (p = 0.684). Weight and height measurements were taken in order to determine body mass index (BMI), waist circumference (WC) and hip circumference (HC), which allowed determining the waist/hip ratio (WHR). There was no initial difference between groups in demographic, socioeconomic, exercising and anthropometric variables (p > 0.05). Group PD recorded the highest weight (p = 0.003), BMI (p = 0.002) and WC (p = 0.033) values at the 30th experimental day. Group PD kept the highest weight loss at the 60th day (p < 0,001), as well as the highest BMI (p < 0.001), WC (p = 0.002) and WHR (p = 0.002) reduction. PD is a feasible option to treat obesity, it led to reduced anthropometric markers. Other studies are necessary to assure the safety of its use for longer periods of time.

An overview of the current state of evidence for the role of specific diets in multiple sclerosis

BACKGROUND

Surveys of people with multiple sclerosis (MS) report that most are interested in using dietary modifications to potentially reduce the severity and symptoms of their disease. This review provides an updated overview of the current state of evidence for the role of specific diets in MS and its animal models, with an emphasis on recent studies including efficacy and safety issues related to dietary manipulations in people with MS.

METHODS

Studies were identified using a PubMed search for each diet in both MS and experimental autoimmune encephalomyelitis, by review of the reference list of papers identified in the search process, and by searching clinicaltrials.gov for ongoing studies. Each study was evaluated and the data was summarized. Each diet was assigned a level of evidence for its use in MS based on the Quality Rating Scheme for Studies and Other Evidence.

RESULTS

Several diets have been explored in people with MS and animal models of MS. Most human trials have been small and non-blinded, limiting their generalizability. Many have also been of short-duration, potentially limiting their ability to find clinically meaningful changes. Presently, insufficient evidence exists to recommend the routine use of any specific diet by people with MS. Clinical trials are ongoing or planned for many diets including the Swank Diet, Wahl's diet, McDougall diet, Mediterranean diet, and intermittent fasting. Results of these studies may help guide clinical recommendations.

CONCLUSION

There is insufficient evidence to recommend the routine use of any specific diet by people with MS. Some diets touted for MS may have potential negative health consequences. It is important that clinicians inquire regarding dietary manipulations, so they can educate patients on any known efficacy data and potential adverse effects of individual diets. Consultation with a registered dietician is recommended for patients undertaking restrictive diets.

Influence of Paleolithic diet on anthropometric markers in chronic diseases: systematic review and meta-analysis

BACKGROUND

The Paleolithic diet has been studied in the scope of prevention and control of chronic noncommunicable diseases (CNCD). The objective of this study was to analyze the influence of the Paleolithic diet on the prevention and control of CNCD in humans, specifically on anthropometric markers, through a systematic review with meta-analysis.

METHODS

What is the effect of the Paleolithic diet on anthropometric parameters (weight, body mass index and waist circumference) compared to other control diets based on recommendations in adults? We included only randomized studies with humans that used the Paleolithic Diet in the prevention and control of CNCD published in Portuguese, English or Spanish. The search period was until March 2019, in the LILACS, PubMed, Scielo, Science Direct, Medline, Web of Science and Scopus databases. The abstracts were evaluated by two researchers. We found 1224 articles, of which 24 were selected and 11 were included in the meta-analysis. The effect of dietary use on body weight, body mass index and waist circumference was evaluated.

RESULTS

The summary of the effect showed a loss of - 3.52 kg in the mean weight (CI 95%: - 5.26; - 1.79; p < 0,001; I² = 24%) of people who adopted the Paleolithic diet compared to diets based on recommendations. The analysis showed a positive association of adopting the Paleolithic diet in relation to weight loss. The effect was significant on weight, body mass index and waist circumference.

CONCLUSION

The Paleolithic diet may assist in controlling weight and waist circumference and in the management of chronic diseases. However, more randomized clinical studies with larger populations and duration are necessary to prove health benefits.

TRIAL REGISTRATION

CRD42015027849 .

A Review of Various Antioxidant Compounds and their Potential Utility as Complementary Therapy in Multiple Sclerosis

Multiple sclerosis (MS) is a complex disease of the central nervous system (CNS). The etiology of this multifactorial disease has not been clearly defined. Conventional medical treatment of MS has progressed, but is still based on symptomatic treatment. One of the key factors in the pathogenesis of MS is oxidative stress, enhancing inflammation and neurodegeneration. In MS, both reactive oxygen and nitrogen species are formed in the CNS mainly by activated macrophages and microglia structures, which can lead to demyelination and axon disruption. The course of MS is associated with the secretion of many inflammatory and oxidative stress mediators, including cytokines (IL-1b, IL-6, IL-17, TNF-α, INF-γ) and chemokines (MIP-1a, MCP-1, IP10). The early stage of MS (RRMS) lasts about 10 years, and is dominated by inflammatory processes, whereas the chronic stage is associated with neurodegenerative axon and neuron loss. Since oxidative damage has been known to be involved in inflammatory and autoimmune-mediated processes, antioxidant therapy could contribute to the reduction or even prevention of the progression of MS. Further research is needed in order to establish new aims for novel treatment and provide possible benefits to MS patients. The present review examines the roles of oxidative stress and non-pharmacological anti-oxidative therapies in MS.

Lipid profile is associated with decreased fatigue in individuals with progressive multiple sclerosis following a diet-based intervention: Results from a pilot study

Purpose

To investigate associations between lipid profiles and fatigue in a cohort of progressive multiple sclerosis (MS) patients on a diet-based multimodal intervention.

Methods

This pilot study included 18 progressive MS patients who participated in a prospective longitudinal study of fatigue following a diet-based multimodal intervention that included exercise, neuromuscular electrical stimulation and stress reduction. The diet recommended high intake of vegetables and fruits, encouraged consumption of animal and plant protein and excluded foods with gluten-containing grains, dairy and eggs. Fatigue was measured on the Fatigue Severity Scale (FSS) at baseline and every 3 months for 12 months. A lipid profile consisting of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and triglycerides (TG) was obtained on fasting blood samples at baseline and 12 months.

Results

FSS scores decreased from a baseline of 5.51 (95% CI: 4.86, 6.16) to a mean of 3.03 (95% CI: 2.23, 3.82) at 12 months (p < 0.001). At 12 months, increases in HDL-C (mean change: +6.0 mg/dl; 95% CI: 0.3, 12.0; p = 0.049) and decreases in BMI (mean change: -2.6 kg/m²; 95% CI: -3.6, -2.5; p < 0.001), LDL-C (mean change: -10.4 mg/dl; 95% CI:-19.7, -1.2; p = 0.029), TG (mean change: -29.2 mg/dl; 95% CI: -44.3, -14.2; p = 0.001), TG to HDL-C ratio (mean change: -0.6; 95% CI: -1.0, -0.3; p = 0.002) and TC to HDL-C ratio (mean change:-0.6; 95% CI: -1.0, -0.3; p = 0.003) were observed compared to baseline. Improvements in FSS were associated with increases in HDL-C (β = -0.05; 95% CI: -0.1, -0.0004; p = 0.048) and changes in TC (p = 0.005) from baseline to 12 months.

Conclusions

Lipid profile variables are associated with improvements in fatigue in progressive MS patients on a diet-based multimodal intervention.

A randomised double-blind placebo-controlled feasibility trial of flavonoid-rich cocoa for fatigue in people with relapsing and remitting multiple sclerosis

The impact of flavonoids on fatigue has not been investigated in relapsing and remitting multiple sclerosis (RRMS).

OBJECTIVE

To determine the feasibility and estimate the potential effect of flavonoid-rich cocoa on fatigue and fatigability in RRMS.

METHODS

A randomised double-blind placebo-controlled feasibility study in people recently diagnosed with RRMS and fatigue, throughout the Thames Valley, UK (ISRCTN69897291). During a 6-week intervention participants consumed a high or low flavonoid cocoa beverage daily. Fatigue and fatigability were measured at three visits (weeks 0, 3 and 6). Feasibility and fidelity were assessed through recruitment and retention, adherence and a process evaluation.

RESULTS

40 people with multiple sclerosis (10 men, 30 women, age 44±10 years) were randomised and allocated to high (n=19) or low (n=21) flavonoid groups and included in analysis. Missing data were <20% and adherence to intervention of allocated individuals was >75%. There was a small effect on fatigue (Neuro-QoL: effect size (ES) 0.04, 95% CI -0.40 to 0.48) and a moderate effect on fatigability (6 min walk test: ES 0.45, 95% CI -0.18 to 1.07). There were seven adverse events (four control, three intervention), only one of which was possibly related and it was resolved.

CONCLUSION

A flavonoid beverage demonstrates the potential to improve fatigue and fatigability in RRMS.

Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto's Thyroiditis

Background Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is an autoimmune disorder affecting the thyroid gland and is the most common cause of hypothyroidism in the US. Despite medical management with thyroid hormone replacement, many individuals with HT continue to experience symptoms and impaired quality of life. Given the limited number of efficacious treatments outside of hormone replacement and the overall burden of continued symptomatic disease, this pilot study was designed to determine the efficacy of a multi-disciplinary diet and lifestyle intervention for improving the quality of life, clinical symptom burden, and thyroid function in a population of middle-aged women with HT. Materials and methods The study recruited 17 normal or overweight (body mass index (BMI) <29.9) female subjects between the ages of 20 and 45 with a prior diagnosis of HT. The 17 women participated in a 10-week online health coaching program focused on the implementation of a phased elimination diet known as the Autoimmune Protocol (AIP). The 36-Item Short Form Health Survey (SF-36) and Cleveland Clinic Center for Functional Medicine's Medical Symptoms Questionnaire (MSQ) were used to measure the participant's health-related quality of life (HRQL) and clinical symptom burden, respectively, before and after the 10-week program. The participants completed serologic testing that included a complete blood cell count (CBC) with differential, complete metabolic profile (CMP), thyroid function tests, including thyroid stimulating hormone (TSH), total and free T4, and total and free T3, thyroid antibodies, including thyroid peroxidase antibodies (TPO) and anti-thyroglobulin antibodies (TGA), and high-sensitivity C-reactive protein (hs-CRP).  Results Sixteen women (n = 16) completed the SF-36 and MSQ before and after the 10-week program. There was a statistically significant improvement in HRQL as measured by all eight subscales of the SF-36 with the most marked improvements noted in the physical role functioning, emotional role functioning, vitality, and general health subscales. The clinical symptom burden, as measured by the MSQ, decreased significantly from an average of 92 (SD 25) prior to the program to 29 (SD 20) after the program. There were no statistically significant changes noted in any measure of thyroid function, including TSH, free and total T4, free and total T3 (n = 12), as well as thyroid antibodies (n = 14). Inflammation, as measured by hs-CRP (n = 14), was noted to significantly decrease by 29% (p = 0.0219) from an average of 1.63 mg/L (SD 1.72) pre-intervention to 1.15 mg/L (SD 1.31) post-intervention. Conclusions Our study suggests that an online diet and lifestyle program facilitated by a multi-disciplinary team can significantly improve HRQL and symptom burden in middle-aged female subjects with HT. While there were no statistically significant changes noted in thyroid function or thyroid antibodies, the study's findings suggest that AIP may decrease systemic inflammation and modulate the immune system as evidenced by a decrease in mean hs-CRP and changes in white blood cell (WBC) counts. Given the improvements seen in the HRQL and participants' symptom burden as well as markers of immune activity and inflammation, further studies in larger populations implementing AIP as part of a multi-disciplinary diet and lifestyle program are warranted.

Nutrient Composition Comparison between the Low Saturated Fat Swank Diet for Multiple Sclerosis and Healthy U.S.-Style Eating Pattern

Multiple sclerosis (MS) is an incurable degenerative disease that attacks the central nervous system. Roy Swank proposed a low saturated fat diet to treat MS around 1950 and showed delayed disease progression in his patients. However, there is insufficient evidence to recommend this diet for MS and default dietary recommendations are the Dietary Guidelines for Americans (DGA). This study assessed the nutritional adequacy of seven-day menus developed by Swank and their compliance with the DGA; menus were modeled for comparison with the DGA Healthy US-Style Eating Pattern (HEP) for males and females 31⁻50 years. Swank recommended dietary supplements corrected menu shortfalls in vitamins D, E, calcium, folate and iron but not dietary fiber, potassium and choline. Healthy Eating Index-2015 score for Swank menus (93.2/100) indicated good compliance with the DGA. Nutritional adequacy of the Swank modeled diet was similar to HEP for 17 vitamins and minerals (Mean Adequacy Ratios ≥94%) with similar shortfall nutrients except magnesium (HEP males) and dietary fiber (Swank males). Alternate Healthy Eating Index-2010 scores for Swank male (90/110) and female (88/110) model diets were similar to HEP. Swank menus have similar nutritional adequacy as HEP. Inclusion of foods high in dietary fiber, potassium and choline may be advised as well as selection of foods to reduce sodium below the Tolerable Upper Intake Level.

Nutrient Composition Comparison between a Modified Paleolithic Diet for Multiple Sclerosis and the Recommended Healthy U.S.-Style Eating Pattern

Multiple sclerosis (MS) is a demyelinating disease that attacks the central nervous system. Evidence-based dietary guidelines do not exist for MS; the default advice is to follow the Dietary Guidelines for Americans (DGA). A modified Paleolithic Wahls Elimination (WahlsElim) diet promoted for MS excludes grains and dairy and encourages 9+ cups fruits and vegetables (F/V) and saturated fat for cooking. This study evaluated the nutritional adequacy of seven-day menus and modeled them with varying amounts of F/V for comparison with the DGA Healthy US-Style Eating Pattern (HEP) for ages 31⁻50 years. WahlsElim menus had low added sugar and glycemic index. Nutritional adequacy of the menus and modeled versions were similar to HEP for 17 vitamins and minerals (mean adequacy ratio ≥92%). Nutrient shortfalls for the modeled diet with 60% F/V were identical to HEP for vitamin D, iron (females), magnesium (marginally males), choline and potassium; this modeled diet was also low in dietary fiber and calcium but met vitamin E requirements while HEP did not. WahlsElim-prescribed supplements corrected vitamin D and magnesium shortfalls; careful selection of foods are needed to meet requirements of other shortfall nutrients and reduce saturated fat and sodium. Doctors should monitor nutritional status, supplement doses, and possible contraindications to high vitamin K intake in individuals following the WahlsElim diet.

Review of Two Popular Eating Plans within the Multiple Sclerosis Community: Low Saturated Fat and Modified Paleolithic

The precise etiology of multiple sclerosis (MS) is unknown but epidemiologic evidence suggests this immune-mediated, neurodegenerative condition is the result of a complex interaction between genes and lifetime environmental exposures. Diet choices are modifiable environmental factors that may influence MS disease activity. Two diets promoted for MS, low saturated fat Swank and modified Paleolithic Wahls Elimination (WahlsElim), are currently being investigated for their effect on MS-related fatigue and quality of life (NCT02914964). Dr. Swank theorized restriction of saturated fat would reduce vascular dysfunction in the central nervous system (CNS). Dr. Wahls initially theorized that detailed guidance to increase intake of specific foodstuffs would facilitate increased intake of nutrients key to neuronal health (Wahls™ diet). Dr. Wahls further theorized restriction of lectins would reduce intestinal permeability and CNS inflammation (WahlsElim version). The purpose of this paper is to review the published research of the low saturated fat (Swank) and the modified Paleolithic (Wahls™) diets and the rationale for the structure of the Swank diet and low lectin version of the Wahls™ diet (WahlsElim) being investigated in the clinical trial.

The Role of Diet in Multiple Sclerosis: Mechanistic Connections and Current Evidence

PURPOSE OF REVIEW

This review seeks to examine current research related to the role of diet in multiple sclerosis (MS).

RECENT FINDINGS

Recent research in preclinical models, epidemiologic studies, and limited prospectively followed cohorts provide preliminary evidence that dietary factors influence MS incidence, disease course, and symptomatology. Current evidence for the effects of fatty acids, fruits and vegetables, whole grains, dairy, and salt are reviewed. Dietary patterns including overall diet quality, caloric restriction, McDougall diet, Paleolithic diet, and Mediterranean diet are discussed. Hypotheses regarding potential mechanistic connections underlying observed effects are also presented. Several individual dietary components and patterns demonstrate potential for significant impact in MS. Definitive answers regarding the ability of diet to act as a disease modifier in MS will ultimately require large-scale clinical trials. Continued prospective studies and clinical trials to further advance this line of research are warranted.

Is there an effect of dietary intake on MS-related fatigue? - A systematic literature review

BACKGROUND

Fatigue is considered the most common symptom of persons with multiple sclerosis MS (pwMS), occurring in up to 90% of the patients at some point with two-thirds of pwMS experience fatigue as their most disturbing symptom. Pharmacological treatment options for MS-related fatigue show only limited and contradicting results. Consequently, many pwMS search for alternative options to control the symptom. A considerable interest in dietary interventions as a means of MS symptom management has advanced in the MS community. Yet, the few empirical studies focussing on the effect of holistic dietary intake on fatigue have not been systematically examined. The aim of this review was to systematically review the effect of holistic dietary intake and the subjective perception of fatigue in adult pwMS.

METHODS

Embase, Medline, Web of Science, CINAHL Complete, SPORTDiscus, PsycInfo, and Rehabilitation and Sports Medicine (Ebsco Host) databases were systematically searched to locate relevant literature. Intervention trials studying the effect of a holistic dietary regimen on the subjective perception of fatigue in a sample of adult pwMS were considered for inclusion. Risk of bias was assessed using a modified Downs and Black checklist.

RESULTS

A total of four studies met the inclusion criteria: one single arm intervention pilot trial, one randomised controlled pilot trial, one double-blinded randomised trial, and one assessor-blinded randomised controlled trial. Interventions were low fat diets, a low fat, starchy plant food diet, and modified paleo diets and ranged from three to 12 months duration. Two studies supplying an adequate amount of folate and magnesium with the intervention diet reported relevant improvements in fatigue scores.

CONCLUSION

Dietary intake holds the potential to lower MS-related fatigue, but solid conclusions are not possible based on the existing evidence. Sparse evidence points towards an effect of adequate magnesium and folate intake and a trend for decreased fatigue.

Is there an overlooked “window of opportunity” in MS exercise therapy? Perspectives for early MS rehabilitation

While early medical treatment has proven effective in MS, early-phase MS rehabilitation has not gained much attention in MS research and clinical practice. Exercise therapy is one of the most promising treatment strategies in MS rehabilitation. Here, we provide a topical review investigating when exercise therapy is initiated in existing MS studies, showing that exercise is initiated at a rather late disease stage, where it predominantly serves as a symptomatic treatment. Recent findings in MS suggest that exercise may have neuroprotective and disease-modifying effects. Such findings along with the findings from medical trials that an early-stage “window of opportunity” exists leads to the proposal that early exercise therapy should be an increased focus in research and clinical practice for persons with MS. A further perspective relates to other rehabilitation interventions that are also initiated at a later disease stage, as these may also take advantage of an early-phase approach.

Dietary approaches to treat MS-related fatigue: comparing the modified Paleolithic (Wahls Elimination) and low saturated fat (Swank) diets on perceived fatigue in persons with relapsing-remitting multiple sclerosis: study protocol for a randomized controlled trial

BACKGROUND

Fatigue is one of the most disabling symptoms of multiple sclerosis (MS) and contributes to diminishing quality of life. Although currently available interventions have had limited success in relieving MS-related fatigue, clinically significant reductions in perceived fatigue severity have been reported in a multimodal intervention pilot study that included a Paleolithic diet in addition to stress reduction, exercise, and electrical muscle stimulation. An optimal dietary approach to reducing MS-related fatigue has not been identified. To establish the specific effects of diet on MS symptoms, this study focuses on diet only instead of the previously tested multimodal intervention by comparing the effectiveness of two dietary patterns for the treatment of MS-related fatigue. The purpose of this study is to determine the impact of a modified Paleolithic and low saturated fat diet on perceived fatigue (primary outcome), cognitive and motor symptoms, and quality of life in persons with relapsing-remitting multiple sclerosis (RRMS).

METHODS/DESIGN

This 36-week randomized clinical trial consists of three 12-week periods during which assessments of perceived fatigue, quality of life, motor and cognitive function, physical activity and sleep, diet quality, and social support for eating will be collected. The three 12-week periods will consist of the following: 1.

OBSERVATION

Participants continue eating their usual diet. 2.

INTERVENTION

Participants will be randomized to a modified Paleolithic or low saturated fat diet for the intervention period. Participants will receive support from a registered dietitian (RD) through in-person coaching, telephone calls, and emails. 3.

FOLLOW-UP

Participants will continue the study diet for an additional 12 weeks with minimal RD support to assess the ability of the participants to sustain the study diet on their own.

DISCUSSION

Because fatigue is one of the most common and disabling symptoms of MS, effective management and reduction of MS-related fatigue has the potential to increase quality of life in this population. The results of this study will add to the evidence base for providing dietary recommendations to treat MS-related fatigue and other symptoms associated with this disease.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02914964 . Registered on 24 August 2016.

Health outcomes and adherence to a healthy lifestyle after a multimodal intervention in people with multiple sclerosis: Three year follow-up

BACKGROUND

Modifiable risk factors such as smoking and sedentary lifestyle adversely affect multiple sclerosis (MS) progression. Few multimodal behavioural interventions have been conducted for people with MS, and follow-up beyond 1 year is rare for lifestyle interventions. This study assessed adoption and adherence to healthy lifestyle behaviours and health outcomes 3 years after a lifestyle modification intervention, using generalized estimating equation models to account for within-participant correlation over time.

METHODS

95 people with MS completed baseline surveys before participating in 5-day MS lifestyle risk-factor modification workshops. 76 and 78 participants completed the 1-year and 3-year follow-up surveys respectively. Mean age at 3-year follow-up was 47 years, 72% were female, most (62.8%) had MS for 5 years or less, and 73% had relapsing remitting MS (RRMS).

RESULTS

Compared to baseline, participants reported clinically meaningful increases in physical (mean difference (MD): 8.0, 95% Confidence Interval (CI): 5.2-10.8) and mental health (MD: 9.2, CI: 5.8-12.6) quality of life (QOL) at 1-year, and physical (MD: 8.7, CI: 5.3-12.2) and mental health (MD: 8.0, CI: 4.2-11.8) QOL at 3-year follow-up. There was a small decrease in disability from baseline to 1-year follow-up (MD: 0.9, CI: 0.9,1.0) and to 3-year follow-up (MD: 1.0, CI: 0.9,1.0), which was not clinically meaningful. Of those with RRMS, compared to baseline, fewer had a relapse during the year before 1-year follow-up (OR: 0.1, CI 0.0-0.2) and 3-year follow-up (OR: 0.15, CI 0.06-0.33). Participants' healthy diet score, the proportion meditating ≥1 hours a week, supplementing with ≥ 5000IU vitamin D daily, and supplementing with omega-3 flaxseed oil increased at 1-year follow-up and was sustained, although slightly lower at 3-year follow-up. However, there was no evidence for a change in physical activity and not enough smokers to make meaningful comparisons. Medication use increased at 1-year follow-up and at 3-year follow-up.

CONCLUSION

The results provide evidence that lifestyle risk factor modification is feasible and sustainable over time, in a small self-selected and motivated sample of people with MS. Furthermore, participation in a lifestyle intervention is not associated with a decrease in MS medication use.

Exploring Wellness Interventions in Progressive Multiple Sclerosis: an Evidence-Based Review

PURPOSE OF REVIEW

There has been recent interest in the role of lifestyle and wellness-based approaches in the treatment and management of multiple sclerosis (MS). These approaches may be particularly relevant for patients with progressive MS, considering limited therapeutic options currently available. The purpose of this review is to examine the role of wellness-based interventions including exercise training, emotional well-being therapies, and dietary modification in patients with progressive MS.

RECENT FINDINGS

We conducted a literature search on the efficacy of wellness-based interventions in patients with progressive MS published between 1985 and July 2017. The level of evidence for each trial was evaluated using the American Academy of Neurology criteria. Overall, 21 articles reporting on 16 wellness-based interventions were identified: ten trials involved exercise training, three involved emotional wellness therapies, two involved dietary modification, and one was a combined wellness intervention. There is level C evidence (possibly effective; one class II study) for the efficacy of aerobic exercise training on cardiorespiratory fitness in patients with progressive MS. There is level B evidence (probably effective; one class I study) for the efficacy of mindfulness training on psychological distress, depression, anxiety, pain, and quality of life in patients with progressive MS. There is inadequate evidence (level U) for efficacy of dietary modification (one class III study and one class IV study) and combined wellness interventions involving exercise training, meditation, and dietary modification (one class IV study). High-quality research is needed to provide evidence-based recommendations for wellness behaviors and lifestyle change in patients with progressive MS.

The Efficacy of Psychological Interventions for Managing Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Background

Multiple sclerosis (MS) is a complex, demyelinating disease of the central nervous system. Fatigue is commonly reported by people with MS (PwMS). MS-related fatigue severely affects daily activities, employment, socioeconomic status, and quality of life.

Objective

We conducted this systematic review and meta-analysis to determine whether psychological interventions are effective in managing fatigue in PwMS.

Data sources

We performed systematic searches of Medline, EMBASE, PsycINFO, and CINAHL to identify relevant articles published from database inception to April 5, 2017. Reference lists from relevant reviews were also searched.

Study selection and design

Two independent reviewers screened the papers, extracted data, and appraised the included studies. A clinical psychologist verified whether interventions were psychological approaches. A narrative synthesis was conducted for all included studies. For relevant randomized controlled trials that reported sufficient information to determine standardized mean differences (SMDs) and 95% confidence intervals (CIs), meta-analyses were conducted using a random-effects model.

Results

Of the 353 identified articles, 20 studies with 1,249 PwMS were included in this systematic review. Narrative synthesis revealed that psychological interventions reduced fatigue in PwMS. Meta-analyses revealed that cognitive behavioral therapy decreased levels of fatigue compared with non-active controls (SMD = −0.32; 95% CI: −0.63 to −0.01) and compared with active controls (relaxation or psychotherapy) (SMD = −0.71; 95% CI: −1.05 to −0.37). Meta-analyses further showed that both relaxation (SMD = −0.90; 95% CI: −1.30 to −0.51), and mindfulness interventions (SMD = −0.62; 95% CI: −1.12 to −0.12), compared with non-active control, decreased fatigue levels. The estimates of heterogeneity for the four meta-analyses varied between none and moderate.

Conclusion

This study found that the use of psychological interventions for MS-related fatigue management reduced fatigue in PwMS. While psychological interventions are generally considered first-line therapy for MS-related fatigue, further studies are needed to explore the long-term effect of this therapy.

[New aspects of symptomatic MS treatment: Part 6 - cognitive dysfunction and rehabilitation]

The symptomatic treatment of multiple sclerosis (MS) is nowadays of similar importance as immunotherapy within a comprehensive treatment concept of this chronic disease. It makes a considerable contribution to the reduction of disabilities in activities of daily living as well as social and occupational life. Moreover, symptomatic treatment is of great importance for amelioration of the quality of life. Since our last survey of symptomatic MS treatment in 2004 and publication of the guidelines of the German Neurological Society and the Clinical Competence Network Multiple Sclerosis ("Klinisches Kompetenznetz Multiple Sklerose", KKN-MS) in 2014 several developments within the topics of mobility, bladder and sexual function, vision, fatigue, cognition and rehabilitation have taken place. These new findings together with further aspects of disease measurement methods and overall treatment strategies of the respective symptoms, as well as treatment goals are introduced in several individual contributions. In this article the symptoms of cognitive disorders and the growing impact of rehabilitation are discussed.

The Evidence for Dietary Interventions and Nutritional Supplements as Treatment Options in Multiple Sclerosis: a Review

PURPOSE OF REVIEW

This review aims to critically evaluate published studies examining diets and nutritional supplements (excepting vitamin D) for the impact on prevention and prognosis of multiple sclerosis (MS).

RECENT FINDINGS

There is a negative relationship between the Mediterranean diet and vascular disease, and vascular co-morbidities are associated with a worse MS prognosis. Low-fat, fish-based diets, sodium-restricted diets, calorie restriction, the paleo diet, and gluten-free diets have been examined, mostly in observational studies; results are inconclusive. With regard to nutritional supplements, pilot data show a possible benefit of biotin with respect to disability worsening in people with progressive MS (PMS). The best designed randomized controlled trials (RCTs) for PUFA supplementation have not shown significant impact, but several weaker RCTs have. Many other nutritional supplements have been tested, including several anti-oxidants. While some early studies show positive results, no result has been definitive. Unfortunately, there is no strong evidence for a direct benefit of any given dietary intervention on MS risk or prognosis. However, due to its relationship with vascular co-morbidities, the Mediterranean diet has the strongest rationale for employment in PwMS. Higher-quality clinical trials are needed to ascertain the possible benefits of nutritional supplements.

Diet, Gut Microbiota, and Vitamins D + A in Multiple Sclerosis

Central to the understanding of the relationships between diet, gut microbiota, and vitamins D and A in multiple sclerosis is low-grade inflammation, which is involved in all chronic inflammatory diseases and is influenced by each of the above effectors. We show that food components have either proinflammatory or anti-inflammatory effects and influence both the human metabolism (the "metabolome") and the composition of gut microbiota. Hypercaloric, high-animal-fat Western diets favor anabolism and change gut microbiota composition towards dysbiosis. Subsequent intestinal inflammation leads to leakage of the gut barrier, disruption of the blood-brain barrier, and neuroinflammation. Conversely, a vegetarian diet, rich in fiber, is coherent with gut eubiosis and a healthy condition. Vitamin D levels, mainly insufficient in a persistent low-grade inflammatory status, can be restored to optimal values only by administration of high amounts of cholecalciferol. At its optimal values (>30 ng/ml), vitamin D requires vitamin A for the binding to the vitamin D receptor and exert its anti-inflammatory action. Both vitamins must be supplied to the subjects lacking vitamin D. We conclude that nutrients, including the nondigestible dietary fibers, have a leading role in tackling the low-grade inflammation associated with chronic inflammatory diseases. Their action is mediated by gut microbiota and any microbial change induced by diet modifies host-microbe interactions in a consequent way, to improve the disease or worsen it.

Diet quality is associated with disability and symptom severity in multiple sclerosis

OBJECTIVE

To assess the association between diet quality and intake of specific foods with disability and symptom severity in people with multiple sclerosis (MS).

METHODS

In 2015, participants in the North American Research Committee on MS (NARCOMS) Registry completed a dietary screener questionnaire that estimates intake of fruits, vegetables and legumes, whole grains, added sugars, and red/processed meats. We constructed an overall diet quality score for each individual based on these food groups; higher scores denoted a healthier diet. We assessed the association between diet quality and disability status as measured using Patient-Determined Disease Steps (PDDS) and symptom severity using proportional odds models, adjusting for age, sex, income, body mass index, smoking status, and disease duration. We assessed whether a composite healthy lifestyle measure, a healthier diet, healthy weight (body mass index <25), routine physical activity, and abstinence from smoking was associated with symptom severity.

RESULTS

Of the 7,639 (68%) responders, 6,989 reported physician-diagnosed MS and provided dietary information. Participants with diet quality scores in the highest quintile had lower levels of disability (PDDS; proportional odds ratio [OR] for Q5 vs Q1 0.80; 95% confidence interval [CI] 0.69-0.93) and lower depression scores (proportional OR for Q5 vs Q1 0.82; 95% CI 0.70-0.97). Individuals reporting a composite healthy lifestyle had lower odds of reporting severe fatigue (0.69; 95% CI 0.59-0.81), depression (0.53; 95% CI 0.43-0.66), pain (0.56; 95% CI 0.48-0.67), or cognitive impairment (0.67; 95% CI 0.55-0.79).

CONCLUSIONS

Our large cross-sectional survey suggests a healthy diet and a composite healthy lifestyle are associated with lesser disability and symptom burden in MS.

Wellness and the Role of Comorbidities in Multiple Sclerosis

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disorder of the central nervous system, for which disease modifying therapies (DMTs) are the mainstay treatment approach to reduce inflammatory disease activity and slow worsening disability. In addition to conventional pharmacologic therapy, there is growing interest in the use of lifestyle strategies to support wellness and mitigate disease-related complications in MS. This interest stems from a growing appreciation of the role of certain comorbidities and lifestyle factors on disease activity, disability, mortality, and overall quality of life. While the current literature is not conclusive, there is evidence to suggest a potential role for vitamin D supplementation, tobacco smoking cessation, routine exercise, a plant-based, anti-inflammatory diet, and maintenance of emotional well-being as adjunct therapies to DMTs. In addition to DMTs, lifestyle strategies should be emphasized as part of a management plan focused on overall health and well-being.

Biological determinants of health: Genes, microbes, and metabolism exemplars of nursing science

BACKGROUND

Increasingly, nurse scientists are incorporating "omics" measures (e.g., genomics, transcriptomics, proteomics, and metabolomics) in studies of biologic determinants of health and behavior. The role of omics in nursing science can be conceptualized in several ways: (a) as a portfolio of biological measures (biomarkers) to monitor individual risk, (b) as a set of combined data elements that can generate new knowledge based on large and complex patient data sets, (c) as baseline information that promotes health education and potentially personalized interventions, and (d) as a platform to understand how environmental parameters (e.g., diet) interact with the individual's physiology.

PURPOSE

In this article, we provide exemplars of nursing scientists who use omics to better understand specific health conditions.

METHODS

We highlight various ongoing nursing research investigations incorporating omics technologies to study chronic pain vulnerability, risk for a pain-related condition, cardiometabolic complications associated with pregnancy, and as biomarkers of response to a dietary intervention.

DISCUSSION

Omics technologies add an important dimension to nursing science across many foci of investigation. However, there are also challenges and opportunities for nurse scientists who consider using omics in their research.

CONCLUSION

The integration of omics holds promise for increasing the impact of nursing research and practice on population health outcomes.

Dietary Interventions and Multiple Sclerosis

Multiple Sclerosis (MS) is a chronic, disabling neurologic disease that has its onset in young adulthood. While the knowledge about underlying pathogenesis of MS has improved significantly over the last few decades, the exact cause still eludes us. Despite the availability of several United States Food and Drug Administration-approved disease-modifying therapies (DMT) for MS in the last two decades, the disease remains disabling for many. DMT use is limited by its partial effectiveness, significant side effects in many cases, and high cost that leads people with MS (PwMS) to look for alternative management options. Dietary intervention as a possible mode to help MS seems very appealing to PwMS; however, scientific data supporting this notion remains sparse. New information on the role of various non-MS health factors, especially vascular disease risk factors such as hypertension, hyperlipidemia, salt intake, and obesity, that may play a role in MS pathogenesis appears very intriguing as it may partly explain the heterogeneity seen in MS activity and disability. This review will highlight the emerging information on various dietary approaches that may affect MS and their possible underlying mechanism.

Influence of the Gut Microbiome on Autoimmunity in the Central Nervous System

Autoimmune disorders of the CNS have complex pathogeneses that are not well understood. In multiple sclerosis and neuromyelitis optica spectrum disorders, T cells destroy CNS tissue, resulting in severe disabilities. Mounting evidence suggests that reducing inflammation in the CNS may start with modulation of the gut microbiome. The lymphoid tissues of the gut are specialized for the induction of regulatory cells, which are directly responsible for the suppression of CNS-damaging autoreactive T cells. Whether cause or effect, the onset of dysbiosis in the gut of patients with multiple sclerosis and neuromyelitis optica provides evidence of communication along the gut-brain axis. Thus, current and future therapeutic interventions directed at microbiome modulation are of considerable appeal.

Effects of a multimodal intervention on gait and balance of subjects with progressive multiple sclerosis: a prospective longitudinal pilot study

PURPOSE

To investigate the effects of a multimodal intervention including a modified Paleolithic diet, nutritional supplements, stretching, strengthening exercises with electrical stimulation of trunk and lower limb muscles, meditation and massage on walking performance and balance of subjects with progressive multiple sclerosis (MS).

MATERIALS AND METHODS

Twenty subjects with mean (standard deviation) age of 51.7 (6.4) years and Expanded Disability Status Scale score of 6.2 (1) participated in a 12-month study. Assessments were completed at baseline, 3, 6, 9, and 12 months.

RESULTS

The entire cohort did not show significant changes in any of the assessments over 12 months except higher speed of walking toward the 10 feet mark during timed up and go (TUG) test at 6 months compared with baseline (mean change 7.9 cm/s [95% confidence interval {CI}]: 0.3, 15.2; p=0.041). Sub-group analysis revealed that 50% subjects (n=10) showed decrease in TUG time from baseline to at least 3 of 4 time-points post-intervention and were considered as responders (TUG-Res), the remaining 10 subjects were considered as nonresponders (TUG-NRes). Over 12 months, TUG-Res showed decreased mean TUG time by 31% (95% CI: -52%, -2%), increased median Berg Balance Scale scores (42 to 47), 30% increase in mean timed 25-foot walk speed (>20% considered clinically significant) and increased speed of walk toward 10 feet mark during TUG by 11.6 cm/s (95% CI: -3.0, 25.9) associated with increases in step lengths and decrease in step duration. TUG-NRes showed deterioration in walking ability over 12 months. Comparison of TUG-Res and TUG-NRes showed no significant differences in adherence to intervention but better stride duration and longer step length at baseline for TUG-Res than for TUG-NRes (p<0.05).

CONCLUSION

A multimodal lifestyle intervention may improve walking performance and balance in subjects with progressive MS who have mild-to-moderate gait impairment, whereas subjects with severe gait impairments may not respond to this intervention. Future trials should assess effects of this intervention in subjects with MS during early stages of the disease.

A Multimodal, Nonpharmacologic Intervention Improves Mood and Cognitive Function in People with Multiple Sclerosis

OBJECTIVE

The objective of this study was to examine whether participation in a 12-month multimodal intervention would improve mood and cognitive function in adults with progressive multiple sclerosis (MS).

METHODS

In this one-arm, open-label feasibility trial, participants were prescribed a home-based multimodal intervention, including (1) a modified Paleolithic diet; (2) an exercise program (stretching and strengthening of the trunk and lower limb muscles); (3) neuromuscular electrical stimulation (EStim) of trunk and lower limb muscles; and (4) stress management (meditation and self-massage). Individuals completed measures of mood (Beck Anxiety and Depression Inventories) and cognitive (Cognitive Stability Index, Cognitive Screening Test, Delis-Kaplan Executive Function System) and executive function (Wechsler Adult Intelligence Scale) at baseline and 3, 6, 9, and 12 months after the start of the intervention. Dosage of the multimodal intervention was assessed at 3, 6, 9, and 12 months.

RESULTS

The more individuals participated in the intervention activities, the greater improvements they had from baseline to 12 months on self-report measures of anxiety (Beck Anxiety Inventory [BAI]; ps = 0.001 to 0.02), depression (Beck Depression Inventory [BDI]; ps = <0.0001 to 0.09), cognitive function (Cognitive Stability Index [CSI/T], Delis-Kaplan Executive Function System [DKEFS]; ps = 0.001 to 0.06), and executive function (Wechsler Adult Intelligence Scale [WAIS]; ps = <0.0001 to 0.09). Mood and cognitive improvements were more closely related to a higher intake of the modified Paleolithic diet than to exercise and stress management dosage. Anxiety and depression changes were evident after just a few months, whereas changes in cognitive function were generally not observed until later in the intervention period. Mood and cognitive function changes from baseline to 12 months were significantly associated with fatigue improvements (ps = <0.0001 to 0.03).

CONCLUSIONS

A modified Paleolithic diet, exercise, EStim, and stress management intervention like this one has the potential to improve the mood and cognitive symptoms that can lead to considerable suffering in people with MS, potentially improving quality of life and function for people with progressive MS.

Randomized control trial evaluation of a modified Paleolithic dietary intervention in the treatment of relapsing-remitting multiple sclerosis: a pilot study

BACKGROUND/OBJECTIVE

A Paleolithic diet may improve fatigue and quality of life in progressive multiple sclerosis (MS) patients, but past research has evaluated the effects of this dietary intervention in combination with other treatments such as exercise. Thus, the purpose of this pilot study was to evaluate a modified Paleolithic dietary intervention (MPDI) in the treatment of fatigue and other symptoms in relapsing-remitting MS (RRMS).

METHODS

We measured the effects of a MPDI in 17 individuals with RRMS. Of 34 subjects randomly assigned to control (maintain usual diet) and intervention (MPDI) groups, nine subjects (one man) completed the control group and eight subjects (one man) completed the MPDI.

RESULTS

Significant improvements were seen in Fatigue Severity Scale score and also in Multiple Sclerosis Quality of Life-54 and time to complete (dominant hand) 9-Hole Peg Test from baseline in MPDI subjects compared to controls. Increased vitamin K serum levels were also observed in MPDI subjects postprotocol compared to controls.

CONCLUSION

A Paleolithic diet may be useful in the treatment and management of MS, by reducing perceived fatigue, increasing mental and physical quality of life, increasing exercise capacity, and improving hand and leg function. By increasing vitamin K serum levels, the MPDI may also reduce inflammation.

Anti-inflammatory nutritional intervention in patients with relapsing-remitting and primary-progressive multiple sclerosis: A pilot study

The aim of this work was to assess the influence of nutritional intervention on inflammatory status and wellness in people with multiple sclerosis. To this end, in a seven-month pilot study we investigated the effects of a calorie-restricted, semi-vegetarian diet and administration of vitamin D and other dietary supplements (fish oil, lipoic acid, omega-3 polyunsaturated fatty acids, resveratrol and multivitamin complex) in 33 patients with relapsing-remitting multiple sclerosis and 10 patients with primary-progressive multiple sclerosis. At 0/3/6 months, patients had neurological examination, filled questionnaires and underwent anthropometric measurements and biochemical analyses. Serum fatty acids and vitamin D levels were measured as markers of dietary compliance and nutritional efficacy of treatment, whereas serum gelatinase levels were analyzed as markers of inflammatory status. All patients had insufficient levels of vitamin D at baseline, but their values did not ameliorate following a weekly administration of 5000  IU, and rather decreased over time. Conversely, omega-3 polyunsaturated fatty acids increased already after three months, even under dietary restriction only. Co-treatment with interferon-beta in relapsing-remitting multiple sclerosis was irrelevant to vitamin D levels. After six months nutritional treatment, no significant changes in neurological signs were observed in any group. However, serum levels of the activated isoforms of gelatinase matrix metalloproteinase-9 decreased by 59% in primary-progressive multiple sclerosis and by 51% in relapsing-remitting multiple sclerosis patients under nutritional intervention, including dietary supplements. This study indicates that a healthy nutritional intervention is well accepted by people with multiple sclerosis and may ameliorate their physical and inflammatory status.