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Seafood, fatty acid biosynthesis genes, and multiple sclerosis susceptibility.

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Seafood, fatty acid biosynthesis genes, and multiple sclerosis susceptibility.

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Clarisa Williams:

Langer-Gould, A., Black, L. J., Waubant, E., Smith, J. B., Wu, J., Gonzales, E. G., Shao, X., Koebnick, C., Lucas, R. M., Xiang, A., & Barcellos, L. F. (2020). Seafood, fatty acid biosynthesis genes, and multiple sclerosis susceptibility. Multiple Sclerosis Journal, 26(12), 1476–1485.

This week I chose gather more information regarding the consumption of Omega-3 as it relates to Multiple Sclerosis. There have been several implications towards a healthier and overall improvement in quality of life for those who consume a Mediterranean diet for individuals with Multiple Sclerosis. This analysis was conducted to determine the impact of changing a modifiable risk factor on the risk of Multiple Sclerosis. Including a higher fish or omega-3 consumption. There are health benefits to increasing the consumption of omega 3 through a greater intake in seafood and fish. Individuals that consumed fish or seafood at least once a week were associated with 44% lower odds of Multiple Sclerosis compared to those that did not consume fish oil, seafood, or fish. Omega-3 consumption is associated with lower risk of metabolic syndrome. Omega-3s are present in foods we regularly have access to. Drawing a connection between omega-3s and Multiple Sclerosis can provide a clearer explanation to supporting a diet such as the Mediterranean diet. This study found that a diet rich in fish or seafood can reduce the risk of developing Multiple Sclerosis. Making adaptations and adjustments to the diets of those who are at a higher risk of developing Multiple Sclerosis can serve as preventative care and treatment.

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--Ivana Djuricic--

Montoya, T., Castejón, M., Muñoz-García, R., & Alarcón-de-la-Lastra, C. (2021). Epigenetic linkage of systemic lupus erythematosus and nutrition. Nutrition Research Reviews, 1-21. doi:10.1017/S0954422421000287

I thought this review was important and interesting because a lot of the time we look for nutritional plans that will alleviate the symptoms of a disease in a big picture approach, but I haven’t really given thought to how nutrients have the ability to epigenetically effect the prevalence and severity of diseases on a smaller, molecular scale. It was interesting how this review approached lupus and nutrition, although it does note that further clinical studies about dietary bioactive compounds are needed for SLE because they have been mostly studied in cancer thus far, it did bring up interesting correlations between epigenetic changes caused by some nutrients and decreases in transcription of genes responsible for downstream inflammatory mediators.

One key finding is that I enjoyed reading about was an animal and subsequent clinical study on curcumin (a polyphenol in turmeric). In the animal studies, a diet supplemented with curcumin improved renal damage and was able to control autoantibody and cytokine production at the onset of lupus. In the clinical trial, a curcumin supplemented diet or curcumin treated T cells from SLE patients regulated the Th17 vs Treg balance of the CD4+ T cells (Th17 will cause a proinflammatory immune response while Tregs work to dampen the immune response against our own cells). Curcumin is known to decrease HAT activity (HAT enzymes work in the process of histone acetylation by transferring an acetyl group to lysine residue on the N terminal tail) in an IL6 promoter and this decrease in activity inhibits the release of IL6 and TNFa (pro-inflammatory cytokines). The study on curcumin also found that daily intake decreases miR21 (miRNAs regulate 60% of mRNA and this is one that is overexpressed in CD4 T cells in SLE patients as compared to controls and correlated to disease activity) and miR155 (regulates B cell activation and survival) levels.

I think this highlights the importance of micronutrients when making a diet plan for SLE patients and makes me realize how powerful our nutrition can be for health. The things we eat can impact and change our genes to make us more or less susceptible to autoimmune disease on a genetic level, which is not something that I realized about nutritional science before this paper.

Clinically, we should look into dietary changes for the SLE patients to see if/how symptoms improve to any degree. Curcumin is just one nutrient listed in this review, so taken together with others mentioned, it is feasible that the addition of certain micronutrients in their diets, based on current data, would improve clinical outcomes for SLE patients. Although as the review mentioned, there is more work that needs to be done to specifically study the effects of these micronutrients on the course of SLE.

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Habitual fish intake negatively correlates with prevalence of frailty among patients with rheumatoid arthritis

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Habitual fish intake negatively correlates with prevalence of frailty among patients with rheumatoid arthritis

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Ellen Reusch
To supplement this week's readings, I found this really interesting article about a research study done to evaluate the impact fish consumption has on the frailty of patients diagnosed with rheumatoid arthritis. Frailty is characterized by metabolic imbalances and multisystem dysregulation, which leads to worse health outcomes in geriatric patients. The study focused on 306 female RA patients. They were asked to answer questions based on their dietary habits, and were also assessed for frailty status using the Study of Osteoporotic Fractures (SOF) criteria. Results of this study showed that habitual fish intake was negatively correlated with frailty status - meaning that patients who habitually consumed fish showed less chance of being classified in the frail category. The RA patients consuming fish more than two times a week had lower prevalence of frailty than those who consumed fish less than two times per week. Additional analyses of the data collected for this study showed that five foods (fish, meat, milk, vegetables, and fruit) were inversely correlated with increased frailty (with fish being the most significant). While this study gives limited information related to the mechanism by which fish intake improves frailty status, it does provide evidence that habitual fish intake may be beneficial for patients wishing to slow the progression of frailty due to rheumatoid arthritis. Clinically, this information could be crucial to patients trying to maintain their health and avoid potential comorbidities caused by rheumatoid arthritis. Additionally, this study could lead to improved nutritional counseling guidelines given to patients with inflammatory conditions, as it is well known that nutrition plays a key role in these types of disease states.

Minamino et. al. (2021), Habitual fish intake negatively correlates with prevalence of frailty among patients with rheumatoid arthritis. Nature. Retrieved February 02, 2022, from: https://www.nature.com/articles/s41598-021-84479-0.pdf

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Joe Devine: Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations?

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Joe Devine: Dietary Habits and Nutrition in Rheumatoid Arthritis: Can Diet Influence Disease Development and Clinical Manifestations?

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Rheumatoid Arthritis is classified by its pro-inflammatory cytokines and symmetrical poly arthritis. Certain diets can exasperate this pro-inflammatory response, and one fo those diets is the western diet. The western diet is a calorically excessive diet that is rich in red meat and salts. These dietary choices can Shape the gut microbiota as well as body composition influencing the effects of Rheumatoid Arthritis. One theory presented in this study was that a high oral iron load from increased red meat could lead to the onset of RA symptoms and increased synovial membrane activity, however, they presented a study that showed no significant difference between the two groups intake of red meat. The group that did present with RA symptoms did have lower incidence of eating fish. One interesting hypothesis the researches presented for future studies was a potential synergistic effect of smoking and salt intake that increased Th17 lymphocyte differentiation and enhanced autoimmunity.

Gioia, C., Lucchino, B., Tarsitano, M. G., Iannuccelli, C., & Di Franco, M. (2020). Dietary habits and nutrition in rheumatoid arthritis: Can diet influence disease development and clinical manifestations? Nutrients, 12(5), 1456. https://doi.org/10.3390/nu12051456

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Dierra Doaks: Pediatric Lupus in South Africa

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Dierra Doaks: Pediatric Lupus in South Africa

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In the reading on Lupus etiology for this week, I remember reading that patients with systemic lupus erythematosus (SLE) of non-Caucasian and African American descent with early disease onset have the poorest long-term prognosis. I decided to research more about patients outside of the U.S and found an article on pediatric lupus in South Africa. SLE is more common and severe in people of African descent than in Caucasians in North America and Europe. However, this article explains that the epidemiology of SLE in Africa is still unknown. Recent studies have shown that the incidence levels of SLE may be higher in Africa than previously thought. Children with SLE usually present with higher SLE activity and can require more therapy than adult-onset patients. Children can also experience more organ damage than adult-onset patients. This research article included the first registry of high risk pediatric SLE patients in South Africa to solve the lack of research for this population. They conducted a cross sectional analysis of 72 patients. The cohort study concluded that the children presented with high disease activity and progress to end organ damage at higher rates than pediatric SLE cohort studies completed in North America.

Dierra Doaks

Lewandowski, Laura Beth. “Pediatric Lupus in South Africa.” ProQuest Dissertations Publishing, 2015. Print.

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Immune  response  to  SARS-CoV2  vaccines  in  multiple  sclerosis  and healthy controls

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Immune  response  to  SARS-CoV2  vaccines  in  multiple  sclerosis  and healthy controls

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These past two years have been scary for many around the world and many are left wondering DO I EVEN HAVE THE ANTIBODIES, well the answer is yes, yes you do! After waiting hopelessly for months with no end in sight during the start of 2020, the COVID-19 vaccine was released and many became hopeful. Those who were less hopeful were those living with auto-immune diseases or those who take immunosuppressants for many different reasons. Personally, I was worried for my mother who lives with Multiple Sclerosis because vaccine protection was a major question for her.

I present this article today to highlight good news on the COVID-19 vaccine and those living with MS. Compared  to  97.4%  in  Healthy Control,  seroconversion  occurred  in 96.7%  (88/91)  untreated pwMS,  97.1%  (135/139)  on  immunomodulatory (IM-DMT)  and  61.1%  (138/226,  p<0.001) on immunosuppressive   DMT   (IS-DMT). These results were determined by quantitating SARS-CoV-2-IgG  response 3 months post-injection of the initial COVID-19 vaccine. Notice a decrease in response on those who take immunosuppressants (duh, we expect this because the vaccine needs a comprehensive immune response). Still a 61% seroconversion is still good enough and much better than 0! This is great news as we continue researching and understanding immune response and how COVID-19 affects us.

Bsteh, G., Hegen, H., Traxler, G., Krajnc, N., Leutmezer, F., Di Pauli, F., Kornek, B., Rommer, P., Zulehner, G., Dürauer, S., Bauer, A., Kratzwald, S., Klotz, S., Winklehner, M., Deisenhammer, F., Guger, M., Höftberger, R., & Berger, T. (2022). Comparing humoral immune response to SARS-CoV2 vaccines in multiple sclerosis and healthy controls: an Austrian prospective multi-center cohort study. European journal of neurology, 10.1111/ene.15265. Advance online publication. https://doi.org/10.1111/ene.15265

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Comparing humoral immune response to SARS‐CoV2 vaccines in multiple sclerosis and healthy controls: an Austrian prospective multi‐center cohort study

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Nutritional Recommendations for Patients with Multiple Sclerosis - Kate Mashburn 

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Nutritional Recommendations for Patients with Multiple Sclerosis - Kate Mashburn 

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https://pubmed.ncbi.nlm.nih.gov/27645350/

There are very few studies researching how diet changes impact symptoms and overall quality of life for patients with multiple sclerosis. However, even with limited research in this area, it has been shown that changes in the diet really do positively impact patients with MS. In this study, a low fat and purely plant-based diet and how that affects symptoms of those living with multiple sclerosis is explored. The specific symptom that is highlighted in this study is fatigue. Once completed, the results showed no improvement in disability or brain MRI. However, BMI and patient’s measures on fatigue significantly improved. It is important to note that the measure of fatigue was self-reported and cannot be scientifically measured. However, any improvements, self-reported or not, is very important for these patients and future patients that are diagnosed with MS. The improvement of BMI can eventually lead to improved vascular health, but a separate, long term study would need to be conducted to conclude that.

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Randomized Controlled Trial

doi: 10.1016/j.msard.2016.07.001.

Affiliations

¹ Department of Neurology, Oregon Health & Science University, USA; Department of Veterans Affairs MS Center of Excellence-West, Portland, OR, USA. Electronic address: yadavv@ohsu.edu.

² Department of Neurology, Oregon Health & Science University, USA; Department of Veterans Affairs MS Center of Excellence-West, Portland, OR, USA.

³ Novant Medical Group, Charlotte, NC, USA.

⁴ MS/MRI Research Group, University of British Columbia, Vancouver, BC, Canada.

⁵ The McDougall Research and Education Foundation, Santa Rosa, CA, USA.

⁶ Department of Neurology, Louisiana State University, New Orleans, LA, USA.

⁷ Department of Neurology, Oregon Health & Science University, USA.

Free article

Randomized Controlled Trial

Free article

doi: 10.1016/j.msard.2016.07.001.

Affiliations

¹ Department of Neurology, Oregon Health & Science University, USA; Department of Veterans Affairs MS Center of Excellence-West, Portland, OR, USA. Electronic address: yadavv@ohsu.edu.

² Department of Neurology, Oregon Health & Science University, USA; Department of Veterans Affairs MS Center of Excellence-West, Portland, OR, USA.

³ Novant Medical Group, Charlotte, NC, USA.

⁴ MS/MRI Research Group, University of British Columbia, Vancouver, BC, Canada.

⁵ The McDougall Research and Education Foundation, Santa Rosa, CA, USA.

⁶ Department of Neurology, Louisiana State University, New Orleans, LA, USA.

⁷ Department of Neurology, Oregon Health & Science University, USA.

Abstract

Background: The role that dietary interventions can play in multiple sclerosis (MS) management is of huge interest amongst patients and researchers but data evaluating this is limited. Possible effects of a very-low-fat, plant-based dietary intervention on MS related progression and disease activity as measured by brain imaging and MS related symptoms have not been evaluated in a randomized-controlled trial. Despite use of disease modifying therapies (DMT), poor quality of life (QOL) in MS patients can be a significant problem with fatigue being one of the common disabling symptoms. Effective treatment options for fatigue remain limited. Emerging evidence suggests diet and vascular risk factors including obesity and hyperlipidemia may influence MS disease progression and improve QOL.

Objectives: To evaluate adherence, safety and effects of a very-low-fat, plant-based diet (Diet) on brain MRI, clinical [MS relapses and disability, body mass index (BMI)] and metabolic (blood lipids and insulin) outcomes, QOL [Short Form-36 (SF-36)], and fatigue [Fatigue Severity Scale (FSS) and Modified Fatigue Impact Scale (MFIS)], in relapsing-remitting MS (RRMS).

Methods: This was a randomized-controlled, assessor-blinded, one-year long study with 61 participants assigned to either Diet (N=32) or wait-listed (Control, N=29) group.

Results: The mean age (years) [Control-40.9±8.48; Diet-40.8±8.86] and the mean disease duration (years) [Control -5.3±3.86; Diet-5.33±3.63] were comparable between the two groups. There was a slight difference between the two study groups in the baseline mean expanded disability status scale (EDSS) score [Control-2.22±0.90; Diet-2.72±1.05]. Eight subjects withdrew (Diet, N=6; Control, N=2). Adherence to the study diet based on monthly Food Frequency Questionnaire (FFQ) was excellent with the diet group showing significant difference in the total fat caloric intake compared to the control group [total fat intake/total calories averaged ~15% (Diet) versus ~40% (Control)]. The two groups showed no differences in brain MRI outcomes, number of MS relapses or disability at 12 months. The diet group showed improvements at six months in low-density lipoprotein cholesterol (Δ=-11.99mg/dL; p=0.031), total cholesterol (Δ=-13.18mg/dL; p=0.027) and insulin (Δ=-2.82mg/dL; p=0.0067), mean monthly reductions in BMI (Rate=-1.125kg/m2 per month; p<0.001) and fatigue [FSS (Rate=-0.0639 points/month; p=0.0010); MFIS (Rate=-0.233 points/month; p=0.0011)] during the 12-month period.

Conclusions: While a very-low fat, plant-based diet was well adhered to and tolerated, it resulted in no significant improvement on brain MRI, relapse rate or disability as assessed by EDSS scores in subjects with RRMS over one year. The diet group however showed significant improvements in measures of fatigue, BMI and metabolic biomarkers. The study was powered to detect only very large effects on MRI activity so smaller but clinically meaningful effects cannot be excluded. The diet intervention resulted in a beneficial effect on the self-reported outcome of fatigue but these results should be interpreted cautiously as a wait-list control group may not completely control for a placebo effect and there was a baseline imbalance on fatigue scores between the groups. If maintained, the improved lipid profile and BMI could yield long-term vascular health benefits. Longer studies with larger sample sizes are needed to better understand the long-term health benefits of this diet.

Keywords: Diet; Fatigue; Low fat; Magnetic resonance imaging; Multiple sclerosis.

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national center for biotechnology information

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Low-fat, plant-based diet in multiple sclerosis: A randomized controlled trial - PubMed

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While a very-low fat, plant-based diet was well adhered to and tolerated, it resulted in no significant improvement on brain MRI, relapse rate or disability as assessed by EDSS scores in subjects with RRMS over one year. The diet group however showed significant improvements in measures of fatigue, ...

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

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

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This review paper compares how the differences in the western and vegetarian diets affect gut microbiome composition and how these bacteria can affect the efficiency of vitamin D in the body.  Sites of inflammation are a primary target in MS progression.  Reducing low grade inflammation may slow the progression of the disease.  The western diet is higher in calories and low in fiber.  It is also considered proinflammatory as there is an increase in TNF, IL-6, and IL-17 in the gut which then travels through the body.  The presence of these cytokines increases permeability of the gut and blood brain barrier.  The gut microflora of those following this diet have reduced microbial diversity.  Conversely, the vegetarian diet has more microbial diversity and the gut microbiome releases higher levels of anti-inflammatory molecules.
Despite high levels of sunlight exposure, MS patients may still have low levels of vitamin D.  The researchers determined that high levels of supplemental vitamin D in the form of cholecalciferol were needed to increase levels in normal levels.  The reason behind this is unclear but may be related to the enzymes that convert vitamin D into its active form or a shortage of available vitamin D receptors (VDR).  The western diet leads to an increase in bile salts which are a ligand for VDRs .  If these receptors are bound to bile salts, vitamin D is unable to maintain the gut barrier leading to the increased permeability seen. The anti-inflammatory effects seen in the gut are the result of co-activation of the VDR by both vitamins D and A.

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The Therapeutic Effect of the Ketogenic Diet in Treating Progressive Multiple Sclerosis

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The Therapeutic Effect of the Ketogenic Diet in Treating Progressive Multiple Sclerosis

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The purpose of the article was to explore the therapeutic effect of a ketogenic diet in treating progressive multiple sclerosis by possibly improving mitochondrial function. Mitochondrial dysfunction is a critical and common step seen in a lot of neurodegenerative diseases which makes it a viable therapeutic target. The neurodegeneration seen in progressive MS patients was suggested to have a possible correlation with glucose hypometabolism, as a study showed lower glucose uptake in the brain of MS patients in comparison to healthy controls, which creates a potential area for therapy using ketone metabolism to increase energy supply. There were various studies performed in mice that showed that the ketogenic diet had anti-inflammatory effect, increase in mitochondrial biogenesis, as well as other neuroprotective properties. However, a key finding in human studies was an improvement in MS patients with a dysfunctional glucose transporter when on a ketogenic diet. This relates to nutritional sciences as it shows a modification in diet such as switching to a ketogenic diet could have such massive effect on the neurodegenerative aspect of progressive MS and provide a possible therapeutic area to explore for treatment of other neurodegenerative diseases. The clinical implication of the study was to identify an alternative source of fuel that may reduce the rate of neurodegeneration in MS patients.

Storoni, & Plant, G. T. (2015). The Therapeutic Potential of the Ketogenic Diet in Treating Progressive Multiple Sclerosis. Multiple Sclerosis International, 2015, 681289–9. https://doi.org/10.1155/2015/681289

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Sidney Harm: Low-fat plant based diets impacts on Multiple Sclerosis 

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Sidney Harm: Low-fat plant based diets impacts on Multiple Sclerosis 

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This randomized-controlled study looked into a low-fat and plant based diet intervention and the impact on multiple sclerosis symptoms and progression. This was a year long study with 61 participants, separated into a control group and a diet intervention group. Between the two groups there was no observed difference between brain MRI, MS relapses or disability within 12 months from individuals in the control and diet group. It was found that the diet group did have improvements within bio markers such as LDL cholesterol, total cholesterol, insulin and a reduction in BMI.

While there wasn’t a significant difference in brain MRI activity between the two groups, seeing that the diet group had improvements in their labs and in a self reported fatigue scale is a promising sign to diet could have an impact on progression of this disease. If an individual can adhere to a low-fat plant based diet this could improve their quality of life, a larger and longer study should be done to see what the long term effects of good adherence of a low-fat plant based diet has. There could’ve been a possibility that there was not any observed difference between the groups brain MRI’s due to the time frame the study was conducted. I would be interested to see what other diets have been looked at, specifically thinking on how the Mediterranean diet would impact a individual with MS.

Yadav, V., Marracci, G., Kim, E., Spain, R., Cameron, M., Overs, S., Riddehough, A., Li, D. K., McDougall, J., Lovera, J., Murchison, C., & Bourdette, D. (2016). Low-fat, plant-based diet in multiple sclerosis: A randomized controlled trial. Multiple sclerosis and related disorders, 9, 80–90. https://doi.org/10.1016/j.msard.2016.07.001

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The role of diet in rheumatoid arthritis

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The role of diet in rheumatoid arthritis

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I decided on this article because a lot of patients are not aware of the most relevant diet they should uphold. The importance of this article is to further challenge clinicians in specifying diets that will aid in importance to their particular patient. A key finding in this research is that the role of obesity and high-fat diets in RA negatively affects the progression of this disease.  In almost all western countries it has become the biggest problem that continues to grow. This implies that RA is the most prevalent here in which diet becomes a huge part of preventing exponential growth. Targeting fat loss as well as low-fat diets in individuals will also help with the harsh forthcomings of this disease. It is found that most patients won’t comply with dietary recommendations, however, it is important for clinicians to have multiple ways a patient can realistically incorporate it into their life. This is why education in disease and nutrition to one’s patient is critical for their health.

Skoczyńska, M., & Świerkot, J. (2018). The role of diet in rheumatoid arthritis. Reumatologia, 56(4), 259–267. https://doi.org/10.5114/reum.2018.77979

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Andrea Ballinger: Effect of nutrient intake on fatigue in MS Patients

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Andrea Ballinger: Effect of nutrient intake on fatigue in MS Patients

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The above study surveys the role nutrient intake make have on fatigue levels in relapse-remitting MS patients. This is important as chronic fatigue is a common indicator and symptom of MS. If fatigue can be managed with appropriate nutrient supplementation, then this could greatly benefit MS patients.

The present study follows the prevalence rates of MS as the study included 25 male subjects and 76 female subjects. To measure fatigue levels of participants, the study utilized the Modified Fatigue Impact Scale, which measures physical, cognitive, and psychosocial fatigue levels. Dietary intake was measured using a food log and compared to dietary reference intake values. Overall, the study observed a significantly lower dietary intake of magnesium and folate in MS patients which correlated with higher fatigue levels. This is important clinically, as folate plays a large role in neurodegenerative diseases. Low serum and cerebrospinal fluid folate levels can impair brain function, contributing to the cognitive fatigue measured by the MFIS. Additionally, magnesium deficiency can induce inflammatory cytokinesis production. Identifying a folate and magnesium deficiency in MS patients can be clinically useful in the management of symptoms and disease progression.

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Sama Bitarafan, ¹ Mohammad-Hossein Harirchian, ² Shahriar Nafissi, ³ Mohammad-Ali Sahraian, ⁴ Mansoureh Togha, ⁴ Fereydoun Siassi, ⁵ Ahmad Saedisomeolia, ¹ Elham Alipour, ¹ Nakisa Mohammadpour, ¹ Maryam Chamary, ¹ Niyaz Mohammadzadeh Honarvar, ¹ and Ali-Akbar Saboor-Yaraghi ¹

Abstract

Keywords: Dietary Intake, Folate, Magnesium, Modified Fatigue Impact Scale, Multiple Sclerosis

Introduction

Multiple sclerosis is a chronic inflammatory disease of the central nervous system. Environmental factors such as diet have a fundamental role in the pathogenesis and progression of MS. The relationship between MS and nutrition has been investigated by several investigators; however, the nutritional status has not been studied among MS patients.

Fatigue is one of the most common complications among MS patients. Although the pathophysiology of fatigue is not yet clear in this population, inflammatory cytokines, axonal atrophy, hypometabolism of specific brain regions, and higher energy requirement are recognized as probable etiologic factors. Nutritional status may affect MS complications such as fatigue. Fatigue can be worsened by an imbalanced diet. Deficiency of some nutrients such as folate and magnesium have been reported in chronic fatigue syndrome (CFS) patients.

One of the most applicable instruments for fatigue evaluation is MFIS; it measures the fatigue impact on physical, cognitive, and psychosocial functioning. The DRI is an indicator that determines the estimated average requirement of nutrients, as the median population intake needs, and calculates the recommended dietary allowance (RDA). RDA is the level of nutrient intake that is sufficient to cover 97.5% of the population's requirement and determines with 2 standard deviations different from median need.

Currently, there are no data on the effect of nutritional status of MS patients on their fatigue status. The aim of this study was to assess the dietary intake of different nutrients in MS patients in comparison with DRI values and its correlation with their fatigue status.

Materials and Methods

Enrolment of subjects

In the present study, 101 relapsing remitting multiple sclerosis (RRMS) patients (according to the McDonald criteria) were enrolled between 2010 and 2012 in the Iranian Center of Neurological Research, Imam Khomeini Hospital, Tehran, Iran. The age of the enrolled population ranged from 20 to 40 years, and their Expanded Disability Status Scale (EDSS) scores from 0 to 4.5. Body mass index (BMI) of patients was lower than 30. Patients were not in the acute phase of the disease and had not relapsed for at least 3 months preceding the study. There was no report of any nutritional supplement intake during the recent 3 months or any medication except weekly interferon beta-1a injection. Patients with alcohol intake, any possible addiction, dysphagia, diabetes, inflammatory bowel disease, and liver, pancreatic, and biliary disorders were excluded from the study.

Clinical characteristics

Age, gender, and anthropometric measurements of all patients were recorded. The survey applied the validated Persian Modified Fatigue Impact Scale self-assessment questionnaires. The items of MFIS were divided into three subscales of physical, cognitive, and psychosocial scores. It can also be computed as a total score (ranges from 0-84). The higher scores indicate the greater fatigue status in patients. Neurologic impairment of the patients was assessed by a neurologist using the Kurtzke EDSS. The patients completed a 24-hour food record for 3 days and then all diaries were checked by a dietitian.

Statistical analysis

Nutritional data were analyzed using Nutritionist IV software (San Bruno, CA, USA, First Data Bank). Statistical analysis was undertaken using SPSS for Windows (version 18; SPSS Inc., Chicago, IL, USA). Student's independent t-test was employed to compare nutrient intake with DRI values (2012). Association between variables was determined using Pearson Correlation Coefficient. Partial correlation was employed for controlling of daily energy intake. P < 0.05 were considered statistically significant.

Results

In the present study, the study population consisted of 101 RRMS patients with mean EDSS of 1.02 ± 0.99, including 25 men (aged 30.24 ± 7.37) and 76 women (aged 31.82 ± 5.96) (). Mean BMI of our patients was 24.21 ± 3.79 kg/m ² ().

Table 1

Mean energy intake was 1965.56 ± 320.98 kcal/day. The intake of carbohydrates, proteins, and fats, respectively, constitute 56.10%, 12.20%, and 31.70% of total daily energy intake. Daily fat intake consists of three subgroups of saturated fatty acid (SFA) that was 8.82% of the daily energy intake, monounsaturated fatty acid (MUFA) that was 12.24% of the daily energy intake, and polyunsaturated fatty acid (PUFA) that was 10.64% of the daily energy intake (data not presented). Mean fiber intake was 14.17 ± 3.71 grams in men, and 14.69 ± 4.59 grams in women; they were significantly lower than DRI values ().

Table 2

Daily dietary intake of vitamin D, folate, calcium, and magnesium were significantly lower than DRI (). In men, zinc was significantly lower and iron was higher than DRI. However, in women iron was significantly below DRI levels ().

After adjusting for daily energy intake, there were significant correlations between increasing total of MFIS, and decreasing daily intake of folate (P = 0.02) and magnesium (P = 0.03) (). This correlation was significant between physical subscale of MFIS and daily intake of folate (P = 0.008) and magnesium (P = 0.003). MFIS scores were not significantly associated with vitamin D and calcium intake, and intake of any nutrients in the present study ().

Table 3

Discussion

In the present study, for the first time, dietary intake of all nutrients (macronutrients and micronutrients), in comparison with DRI values, were assessed in RRMS patients (separately in men and women). Moreover, correlations between daily intake of all nutrients and fatigue scores were evaluated.

DRI values are the minimum amount of each nutrient's intake that is necessary for healthy persons. Thus, DRI may be different for individuals with specific diseases such as MS. In MS patients, during disease progression, many nutrients' requirements, such as zinc and iron, are increased. Therefore, in this study DRI was used instead of a control group for assesment of nutritional status of MS patients. Some researchers, such as Timmerman and Stuifbergin, and Saka et al., also used DRI instead of a control group for diet evaluation in MS patients.

Considering that the disability of MS patients affect their dietary intake and obesity augments MS patients disability and fatigue, in this study many confounder factors were controlled by inclusion criteria.

These factors are as follows:

Severity of disability: Mean EDSS of patients was 1.02 ± 0.99.

Obesity: All patients' BMI were < 30.

The course of disease: All patients were RRMS.

Supplementation: No patients used any supplements.

Male to female ratio: This ratio obtained 1/3 that was representative of MS prevalence in the Iranian population.

The results obtained in this study were discussed in two ways:

Results of this study showed that mean daily energy intake (1965.56 ± 320.98 kcal/day) and percentage of total daily energy provided by carbohydrates (56.1%), proteins (12.2%), and fats (31.7%) were in accordance with DRI. These findings are in line with the study of Saka et al. that similarly showed the percentage of total energy of the carbohydrates (46.9%), proteins (14.6%), and fats (38.4%) were approximately according to DRI

In this study, male and female patients received 37.28% and 58.76% of the daily recommendations for fiber, which confirms results of the studies by Hewson et al. and Timmerman and Stuifbergin. In our study, daily intake of MUFA (12.24% of energy) and PUFA (10.64% of energy) were in accordance with DRI. Another study showed that MS patients and healthy subjects receive similar amounts of different fatty acids.

Among micronutrients the daily intake of which were measured, followed nutrients intake were lower than DRI values in the diet of MS patients.

Dietary intake of zinc among male patients was lower than DRI. The findings of the study of Ramsaransing et al. indicated that dietary intake of zinc was lower than DRI in MS patients regardless of their gender.

Dietary intake of iron among female patients was lower than DRI; however, iron intake was higher than DRI among male patients. Timmerman and Stuifbergin found that women with MS had an iron consumption higher than that recommended; this result was not in agreement with our findings.

We found that daily calcium intake was lower than DRI among both male and female patients. This finding is in accordance with the study of Timmerman and Stuifbergin that surveyed the nutritional status in women with MS and found that calcium intake is lower than recommended. Because of the high saturated fat content of dairy products, MS patients are commonly advised to refrain from eating these products. This may explain their lower calcium intake. Not only is it not clear whether the lower intake of dairy products can improve the disease progression, but also Ramsaransing et al. showed that low calcium and iron intake may be correlated with progression of MS.

Daily intakes of magnesium and folate were lower than DRI values in our study. These results confirmed the findings of Ramsaransing et al. that showed a lower intake of magnesium and folate in MS patients in comparison to DRI.

Vitamin D intake of our MS patients was significantly lower than DRI values. Several studies have shown that most MS patients are vitamin D deficient in comparison with the healthy population. Due to immunoregulatory properties, vitamin D deficiency is considered as a risk factor for MS.

Higher prevalence of fatigue among MS patients is a major concern and is defined as a subjective lack of mental or physical energy. In the present study, no daily nutrient's intake, except magnesium and folate, was correlated with fatigue scores. We found that lower dietary intake of magnesium and folate in MS patients is correlated with higher score of MFIS and its physical subscale.

As previously shown, deficiency of magnesium can be a risk factor for MS. It has been reported that red blood cells' magnesium levels in chronic fatigue syndrome patients were lower than normal values. It is interesting that the symptoms of CFS and magnesium deficiency are similar. In addition, magnesium supplementation can improve the symptoms of CFS when deficiency of this nutrient is presented. Yasui et al. found the concentration of magnesium in the central nervous system of MS patients to be lower than controls.

Mechanism of exacerbation of MS symptoms in magnesium deficiency is probably the reduction of enzyme inhibition of nitric oxide synthase and production of more nitric oxide in macrophages. Magnesium deficiency can also induce inflammatory cytokines production.

Folate is considered as an important nutrient in neurodegenerative diseases. Moreover, folic acid levels are reduced in cerebrospinal fluid of many CFS patients. Chronic reduction of serum and then cerebrospinal fluid folate level, results in lower brain folate content that may impair brain function and induce CFS. Godfrey et al. and Jacobson et al. found that folate supplementation showed positive effects on CFS improvement. The mechanisms of folate action is not fully understood; however, this molecule can reduce the circulatory level of homocysteine, a cytotoxic amino acid for neural cells.

This is a preliminary study and may provide some direction for further researches. For further researches, we suggest measuring serum level of nutrients, using food frequency questionnaire (FFQ) besides food records, and designing clinical trials.

We did not measure the serum levels of the studied nutrients. Furthermore, we did not compare dietary intake of MS patients with a healthy control group. These are the limitations of the present study. Therefore, we interpret our data cautiously due to this limitation and only emphasize the significant association among low folate and magnesium diets and increasing of fatigue score in MS patients. Assessment and improvement of nutritional status of MS patients should account as a complementary approach to their usual treatments. The evaluation of the nutritional status of patient with MS and designing a program for correction of nutrient deficiencies according to DRI levels, are strongly recommended. This may be effective in MS patients achieving a healthy life and improving their fatigue status.

Conclusion

The results of nutritional status analysis of 101 RRMS patients showed that dietary intakes of vitamin D, folate, calcium, and magnesium were lower than DRI. Lower magnesium and folate diets were correlated with higher fatigue scores in these patients. To our knowledge, there is no nutritional recommendation as complementary therapy in treatment of fatigue related to multiple sclerosis. Therefore, as a preliminary study this result can be helpful. We suggest recognizing and correcting the low dietary intake of nutrients in MS patients, according to DRI values, with specific consideration to folate and magnesium. This may improve fatigue syndrome in MS patients.

Acknowledgments

This research has been supported by Tehran University of Medical Sciences and Health Services Grant. The authors are grateful for the cooperation of all colleagues in the Department of Nutrition, Imam Khomeini Neurology Research Center, and Tehran University of Medical Sciences.

Notes

How to cite this article: Bitarafan S, Harirchian MH, Nafissi Sh, Sahraian MA, Togha M, Siassi F, et al. Dietary intake of nutrients and its correlation with fatigue in multiple sclerosis patients. Iran J Neurol 2014; 13(1): 28-32.

Conflict of Interests

The authors declare no conflict of interest in this study.

References

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Dietary intake of nutrients and its correlation with fatigue in multiple sclerosis patients

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The role of nutrition in the progression of multiple sclerosis (MS) and related complications such as fatigue has been reported by several studies. The aim of this study is the assessment of nutritional status and its relationship with fatigue in multiple ...

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Diet and lupus: what do the patients think?

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Diet and lupus: what do the patients think?

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For this week's assignment I decided to go with this paper that examined the experiences of lupus erythematosus patients with their diet.

As we learnt in this week's module, there are currently no established dietary regimens for the treatment of Lupus. However, methods such as vitamin D supplementation and the consumption of anti-inflammatory nutrients have been proposed to help.

For this study, the researchers conducted an online survey using a 15-point questionnaire, which attracted 284 lupus patients. The goal of the questionnaire was to get the patient's perspective about dietary choices as it relates to lupus.

The striking results of this study for me was that 76% of the patients said they had never received any sort of dietary advice to manage the condition and 100% of the respondents said that they were willing to change their dietary choices if it would help their symptoms.

For me, I don't find it surprising that the patients received little to no advice regarding a dietary plan for lupus management because  a lot of scientifically-proven information is yet unavailable regarding dietary intervention.

This further reiterates the need for more nutritional research targeted at the management of auto-immune diseases like lupus.

Robinson GA, Mcdonnell T, Wincup C, Martin-Gutierrez L, Wilton J, Kalea AZ, Ciurtin C, Pineda-Torra I, Jury EC. Diet and lupus: what do the patients think? Lupus. 2019 May;28(6):755-763. doi: 10.1177/0961203319845473. Epub 2019 Apr 26. PMID: 31027464.

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Rhoda Inimgba: Nutrient Composition Comparison betweena Modified Paleolithic Diet for Multiple Sclerosis andthe Recommended Healthy U.S.-Style Eating Pattern.

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Rhoda Inimgba: Nutrient Composition Comparison betweena Modified Paleolithic Diet for Multiple Sclerosis andthe Recommended Healthy U.S.-Style Eating Pattern.

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The purpose of this study was to compare the nutritional intake of the WahlsElim diet and the Dietary Reference Intakes in people with multiple sclerosis. This is important because having a report on the WahlsElim diet and how it supplements the different nutrition missing in people with multiple sclerois will provide them with more dietary guidelines to improve their health.
The paleolithic WahlsElim diet does not include grains and dairy but encourages at least 9 cups of fruits and vegetables and also saturated fat for cooking. The menu also showed low added sugar and glycemic index. A major finding was that the WahlsElim diet met the vitamin E and vitamin D requirement while The US Healthy Eating pattern did not. This relates to nutritional sciences because it shows that this modified paleolithic diet can supplement for the vitamins missing in people with multiple sclerosis though food still needs to be selected carefully to be able to reduce saurated fat and sodium.
Clinically, this study has shown that there are ways that the diet of patients with multiple sclerosis can be modified to supplement for the nutrition they are missing and also provide them with more dietary guidelines to improve their nutrition and overall health. Therefore, combining this diet and mindful watching the food they eat and their medications can improve their health.
Chenard, C., Rubenstein, L., Snetselaar, L., & Wahls, T. (2019). Nutrient composition comparison between a modified paleolithic diet for multiple sclerosis and the recommended healthy u.s.-style eating pattern. Nutrients, 11(3), 537. https://doi.org/10.3390/nu11030537 .

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Seonwook Kim: Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study

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Seonwook Kim: Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study

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My selected article is about Mediterranean diet (Med Diet) on disease activity and cardiovascular risk in systemic lupus erythematosus (SLE) patients. The study was a cross-sectional study on 280 patients with SLE. It is important because this study assessed, for the first time, the association between adherence to the Med Diet and SLE activity, damage accrual, and Cardiovascular risk markers. One of the key findings is that SLE patients with higher Med Diet adherence had better anthropometric profiles and serum levels of cardiovascular risk and inflammatory markers. The Med Diet group ate nutritionally balanced meals that contain olive oil, fruits, vegetables, legumes, fish, and nuts, as well as abstaining from red meats, meat products, sugary foods, and pastries. And this method could lower overall disease activity. Clinically, this Med Diet style can help the disease state by changes in the immune system, inflammatory markers, and other cardiovascular risk factors. Med Diet is not only ameliorating SLE activity but also downregulating cardiovascular risk factors. Therefore this can be used as combinational therapy with medication to improve the disease.

Pocovi-Gerardino G, Correa-Rodríguez M, Callejas-Rubio JL, Ríos-Fernández R, Martín-Amada M, Cruz-Caparros MG, Rueda-Medina B, Ortego-Centeno N. Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study. Rheumatology (Oxford). 2021 Jan 5;60(1):160-169. doi: 10.1093/rheumatology/keaa210. PMID: 32594173.

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Affiliations

¹ Instituto de Investigación Biosanitaria, IBS, Granada.

² Nursing Department, Faculty of Health Sciences, University of Granada, Armilla, Granada.

³ Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario San Cecilio, Granada.

⁴ Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Complejo Hospitalario de Jaén, Jaén.

⁵ Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital de Poniente, El Ejido.

⁶ Departamento de Medicina, Facultad de Medicina, Universidad of Granada, Granada, Spain.

Affiliations

¹ Instituto de Investigación Biosanitaria, IBS, Granada.

² Nursing Department, Faculty of Health Sciences, University of Granada, Armilla, Granada.

³ Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario San Cecilio, Granada.

⁴ Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Complejo Hospitalario de Jaén, Jaén.

⁵ Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital de Poniente, El Ejido.

⁶ Departamento de Medicina, Facultad de Medicina, Universidad of Granada, Granada, Spain.

Abstract

Objective: To analyse the influence of the Mediterranean diet (Med Diet) on SLE activity, damage accrual and cardiovascular disease risk markers.

Methods: A cross-sectional study was conducted on 280 patients with SLE [46.9 (12.85) years]. Med Diet adherence was assessed through a 14-item questionnaire on food consumption frequency and habits (total score from 0 to 14 points; higher score is greater adherence to the Med Diet). CRP, homocysteine, SLEDAI-2K (SLE disease activity), and SLICC/ACR and SDI (damage accrual) were measured. Obesity, diabetes mellitus, hypertension and blood lipids, among others, were considered cardiovascular disease risk factors.

Results: Greater adherence to the Med Diet was significantly associated with better anthropometric profiles, fewer cardiovascular disease risk factors, and lower disease activity and damage accrual scores (P ≤ 0.001 for SLEDAI and SDI). An inverse relationship between the Med Diet score and SLEDAI (P ≥ 0.001; β = -0.380), SDI (P ≤ 0.001; β = -0.740) and hsCRP (P = 0.039; β = -0.055) was observed. The odds ratio for having active SLE (SLEDAI ≥5) or the presence of damage (SDI ≥1) was lower among patients whose Med Diet score was higher (P ≤ 0.001). Finally, greater consumption of Med Diet foods (olive oil, fruits, vegetables, fish, etc.) and abstaining from red meat and meat products, sugars and pastries was associated with less SLE clinical activity and damage.

Conclusion: Greater adherence to the Med Diet seems to exert a beneficial effect on disease activity and cardiovascular risk in SLE patients. To confirm these findings, further longitudinal studies would be of interest.

Keywords: Mediterranean diet; atherosclerosis; autoimmune; cardiovascular disease; inflammation; lupus; systemic lupus erythematosus.

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cardiovascular diseases / prevention & control*

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patient compliance / statistics & numerical data

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national center for biotechnology information

# data[].attributes.attachment_link.title
Beneficial effect of Mediterranean diet on disease activity and cardiovascular risk in systemic lupus erythematosus patients: a cross-sectional study - PubMed

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1 Instituto de Investigación Biosanitaria, IBS, Granada. 2 Nursing Department, Faculty of Health Sciences, University of Granada, Armilla, Granada. 3 Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario San Cecilio, Granada. 4 Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Complejo Hospitalario de Jaén, Jaén.

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Dietary habits, serum concentration of copper, zinc, and Cu-to-Zn ratio, and ability status of patients with relapsing-remitting MS

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Dietary habits, serum concentration of copper, zinc, and Cu-to-Zn ratio, and ability status of patients with relapsing-remitting MS

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The aim of this study was to determine the influence of diet on the serum concentrations of copper (Cu), zinc (Zn) and the effect of Cu-Zn ratio on ability status (using the Expanded Disability Status Scale) for patients with relapsing-remitting multiple sclerosis (MS). The authors found that serum Zn was significantly lower in MS individuals compared to healthy individuals (control), and that the ratio of Cu to Zn was higher in MS patients. Lower ability status was found in patients with this imbalanced ratio of Cu to Zn.

A high level of Cu can be detrimental as seen in the Fenton reaction, where Cu is involved in the formation of oxygen free radicals generating oxidative stress. A high level of serum Cu could contribute to the low absorption of Zn. A Zn deficiency increases the generation of inflammatory cytokines and oxidative stress and induces endothelial cell dysfunction, which is involved in the pathogenesis of MS. The level of Zn depends on the levels of Cu because this element competes with Zn for binding to metallothionein, which would reduce absorption. This ratio of Cu to Zn is potentially a marker of oxidative stress.

Including foods sources of dietary zinc could improve the clinical condition of individuals with MS. Bioavailability of Zn is relatively high in meat, eggs, and seafood. Many foods have both zinc and copper, which is important to maintain a balanced ratio.

Socha, K., Karpińska, E., Kochanowicz, J., Soroczyńska, J., Jakoniuk, M., Wilkiel, M., Mariak, Z. D., & Borawska, M. H. (2017). Dietary habits; concentration of copper, zinc, and Cu-to-Zn ratio in serum and ability status of patients with relapsing-remitting multiple sclerosis. Nutrition, 39-40, 76–81. https://doi.org/10.1016/j.nut.2017.03.009

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Affiliations

¹ Department of Bromatology, Medical University of Bialystok, Poland. Electronic address: katarzyna.socha@umb.edu.pl.

² Department of Bromatology, Medical University of Bialystok, Poland.

³ Department of Invasive Neurology, Medical University of Bialystok, Poland.

⁴ NZOZ "Kendron" Bialystok, Poland.

⁵ Department of Neurosurgery, Medical University of Bialystok, Poland.

Affiliations

¹ Department of Bromatology, Medical University of Bialystok, Poland. Electronic address: katarzyna.socha@umb.edu.pl.

² Department of Bromatology, Medical University of Bialystok, Poland.

³ Department of Invasive Neurology, Medical University of Bialystok, Poland.

⁴ NZOZ "Kendron" Bialystok, Poland.

⁵ Department of Neurosurgery, Medical University of Bialystok, Poland.

Abstract

Objective: Dietary habits and adequate intake of antioxidants in the diet-for example, copper (Cu) and zinc (Zn)-may be an environmental factor in the occurrence of multiple sclerosis (MS). The aim of this study was to estimate the influence of dietary habits on the concentration of Cu, Zn in the serum, and the effect of Cu-to-Zn ratio on the ability status of patients with relapsing-remitting MS.

Methods: This was an observational case-control study that included 101 individuals with MS and 68 healthy individuals (controls). Food frequency questionnaires were used to collect dietary data. Serum concentrations of Cu and Zn were determined by the electrothermal and flame atomic absorption spectrometry method, respectively. The ratio of Cu to Zn was calculated and compared with the Expanded Disability Status Scale of patients.

Results: The concentration of Zn was significantly lower in the serum of individuals with MS (0.776 ± 0.195 mg/L) than in the control group (0.992 ± 0.315 mg/L). The ratio of Cu to Zn was higher in the examined patients (1.347 ± 0.806) than in the healthy volunteers (1.012 ± 0.458). Lower ability status (P < 0.05) was revealed in patients with an abnormal ratio of Cu to Zn, particularly, in cerebellar function, pyramidal tracts, and emotional conditions. Selected dietary habits have a significant influence on Cu and Zn concentration in the serum of patients with MS.

Conclusions: Lower serum concentrations of Zn and higher ratio of Cu to Zn in patients with MS can suggest a relationship between MS and oxidative stress. Products that are a source of Zn should be included in the diet, which can improve the clinical condition of people with MS.

Keywords: Ability status; Copper; Cu-to-Zn ratio; Dietary habits; Multiple sclerosis; Zinc.

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Bredholt M, Frederiksen JL. Bredholt M, et al. ASN Neuro. 2016 Jun 9;8(3):1759091416651511. doi: 10.1177/1759091416651511. Print 2016 Jun. ASN Neuro. 2016. PMID: 27282383 Free PMC article. Review.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Dietary habits; concentration of copper, zinc, and Cu-to-Zn ratio in serum and ability status of patients with relapsing-remitting multiple sclerosis - PubMed

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Lower serum concentrations of Zn and higher ratio of Cu to Zn in patients with MS can suggest a relationship between MS and oxidative stress. Products that are a source of Zn should be included in the diet, which can improve the clinical condition of people with MS.

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Randomized-controlled trial of a modified Mediterranean dietary program for multiple sclerosis: A pilot study

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Randomized-controlled trial of a modified Mediterranean dietary program for multiple sclerosis: A pilot study

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This article focused on a pilot study of female multiple sclerosis patients that were prescribed to follow a Mediterranean diet while receiving an educational background on the diet in a clinical setting. The purpose of the educational sessions was to increase adherence to the diet plan, therefore increasing the diets effectiveness. There were significant results indicating a reduction in patient fatigue, severity of symptoms and expanded disability status in patients that were a part of the diet intervention group. This relates to nutritional studies because a Mediterranean diet is being implemented in these patients’ treatment plans. The clinical implications of this study can be seen in the increased effectiveness due to the monthly sessions and attendance to educational sessions. Further studies can be done with the implementation of the dietary intervention group’s guidelines to test the impact of potential dietary treatments. I believe that providing an engaging educational atmosphere for the patients increased their likelihood to follow the diet, and therefore they saw better results.

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Esraa Zamzami: A dual effect of ursolic acid to the treatment of multiple sclerosis through both immunomodulation and direct remyelination

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Esraa Zamzami: A dual effect of ursolic acid to the treatment of multiple sclerosis through both immunomodulation and direct remyelination

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This study is important because there are many medications for Multiple Sclerosis (MS); however, all of them are immunosuppressive and non are therapeutic. This study provides promising evidence that ursolic acid (UA) has both immunomodulatory to decrease inflammation and therapeutic effects to stimulate and increase remyelination. The main key finding in this study is that UA has the ability to stimulate the maturation of oligodendrocytes and promote the production of myelin basic protein (MBP) to enhance remyelination. This information directly relates to nutrition because UA is a natural triterpene compound found in food, like in rosemary, sage, and especially in the skin of fruits like apple peel and grape skin. The clinical implication is that MS patients increase their fruit consumption and, more importantly, eat them with their skin after washing them properly. UA toxicity is very high and cannot be reached by food consumption, so it is usually safe.

Zhang, Y., Li, X., Ciric, B., Curtis, M. T., Chen, W. J., Rostami, A., & Zhang, G. X. (2020). A dual effect of ursolic acid to the treatment of multiple sclerosis through both immunomodulation and direct remyelination. Proceedings of the National Academy of Sciences of the United States of America, 117(16), 9082–9093. https://doi.org/10.1073/pnas.2000208117

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Katelyn Spain: An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis

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Katelyn Spain: An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis

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The purpose of this study was to determine if the Mediterranean diet opposed to the Western Diet was more effective in suppressing disease symptoms in patients with rheumatoid arthritis. Since the Mediterranean diet can be beneficial to some rheumatoid arthritis patients, this study can support the dietary interventions in treatment of rheumatoid arthritis. It was found in this study that patients with rheumatoid arthritis treated with the Mediterranean diet had a reduction in inflammatory activity, an increase in physical function, and overall improved vitality. The patients that were considered the control, consuming a normal Western diet, had no significant changes in their inflammatory activities, physical functions and vitalities. This study relates to nutritional sciences because it shows how a change in diet can treat an autoimmune disorder. The clinical implications of this study are that physicians can recommend this diet change to their patients with rheumatoid arthritis because of the high consumption of omega-3 fatty acids and anti-inflammatory phytochemicals in the Mediterranean diet, that are not present in the Western diet. These components of the Mediterranean diet decrease inflammation in patients with rheumatoid arthritis.

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Objective: To investigate the efficacy of a Mediterranean diet (MD) versus an ordinary Western diet for suppression of disease activity in patients with rheumatoid arthritis (RA).

Methods: Patients with well controlled, although active RA of at least two years' duration, who were receiving stable pharmacological treatment, were invited to participate. All patients were randomly allocated to the MD or the control diet (CD). To achieve good compliance with prescribed diets all patients were for the first three weeks served the MD or the CD, respectively, for lunch and dinner at the outpatient clinic's canteen. Clinical examinations were performed at baseline, and again in the 3rd, 6th, and 12th week. A composite disease activity index (DAS28), a physical function index (Health Assessment Questionnaire (HAQ)), a health survey of quality of life (Short Form-36 (SF-36)), and the daily consumption of non-steroidal anti-inflammatory drugs were used as primary efficacy variables.

Results: From baseline to the end of the study the patients in the MD group (n=26) showed a decrease in DAS28 of 0.56 (p<0.001), in HAQ of 0.15 (p=0.020), and in two dimensions of the SF-36 Health Survey: an increase in "vitality" of 11.3 (p=0.018) and a decrease in "compared with one year earlier" of 0.6 (p=0.016). For the control patients (n=25) no significant change was seen at the end of the study. This difference between the two treatment groups was notable only in the second half of the trial.

Conclusion: The results indicate that patients with RA, by adjusting to a Mediterranean diet, did obtain a reduction in inflammatory activity, an increase in physical function, and improved vitality.

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An experimental study of a Mediterranean diet intervention for patients with rheumatoid arthritis

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Objective: To investigate the efficacy of a Mediterranean diet (MD) versus an ordinary Western diet for suppression of disease activity in patients with rheumatoid arthritis (RA). Methods: Patients with well controlled, although active RA of at least two years' duration, who were receiving stable pharmacological treatment, were invited to participate.

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The Impact of Nutrition & Generally Available Products on Rheumatoid Arthritis

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The Impact of Nutrition & Generally Available Products on Rheumatoid Arthritis

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In light of the topics for this week, I wanted to focus on the link between nutrition and Rheumatoid Arthritis (RA). This literature review complied 39 research papers looking into the affects of generally available products on RA. The most common of these products included alcohol, coffee & tea, meat & meat products, and the Mediterranean diet. This review is important because it combines previous information in terms of nutrition and RA and evaluates them to see if certain nutrients can be beneficial to someone with RA. By looking at multiple results at once, it can help to further make sense of them. I also feel that this review is important because it not only acknowledges what is good about the studies, but also where each study falls short.

One key finding of this review is that none of the studies showed a definitive yes or no as to whether or not the nutrients were beneficial to people with RA. This is consistent with many many diseases involving diet. A few of the studies showed that moderate alcohol consumption could lower the risk of RA/modify it's symptoms, but not all of these studies had the same idea of "moderate" (for ex: one study considered one drink as 16 grams, while another study considered a drink to be 500mL and only suggested 15 grams a week).

The clinical implications of this review relate to what we have learned so far this week: while there are suggested dietary intakes, what will work best is specific to each individual. Therefore, individuals should monitor what they eat and how their body reacts to it.

Grygielska, J., Raciborski, F., Kłak, A., & Owoc, J. (2018, May 9). The impact of nutrition and generally available products such as nicotine and alcohol on rheumatoid arthritis - review of the literature. Reumatologia. Retrieved January 29, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5974635/

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Abstract

Nutrition habits and diet may influence disease development and course. There are no specific recommendations related to rheumatic diseases for a diet that would facilitate treatment. However, some research results suggest that various nutrients may affect the health of patients, especially in the case of inflammatory rheumatic disease such as rheumatoid arthritis (RA). Scientists have been trying to find a relation between inflammatory rheumatic diseases and diet but have never come up with any firm conclusions that would help in determining the model of a diet for such patients. Nevertheless, there are some consistent results that refer to the influence of nutritional behaviours on symptoms of RA. The article presents a review of the research showing that certain nutrients may be beneficial for the course of disease among some RA patients.

Keywords: rheumatic diseases, diet, nutrients, smoking, alcohol

Introduction

There is no diet dedicated to rheumatic patients as is the case with other disorders such as diabetes or cardio-vascular disorders. Many diseases in rheumatology have one common denominator, which is the inflammatory processes taking place in the human body. Unpredictability in the course of inflammatory rheumatic diseases is another difficulty in daily life and treatment: there are periods of deterioration in symptoms or remissions.

Hippocrates asserted a long time ago that proper nutrition may reduce symptoms of a disease: "let food be thy medicine and medicine be thy food". The phrase has been present in many papers for years although Hippocrates's authorship is not so certain. Nevertheless, it is unquestionable that nutrition was an important part of human health used to fight diseases even in ancient times [ 1].

Facilitating treatment of rheumatoid arthritis (RA) through appropriate nutrition was a subject of interest for physicians and scientists in the 1920s and 1930s. In the "Generic and Specific Influences of Nutrition in the Total Support of Arthritics" paper published in 1942 the authors Ralph Pemberton and C. Wesler Scull said that an active intervention must proceed against all destructive influences within a body: physical fatigue, anaemia, nervous or endocrine imbalance, faulty nutrition, postural defects, and focal infection. The authors asserted that proper nutrition should be an element of therapeutic programmes for people with inflammatory arthritis. Recommendations for a diet rich in proteins with reasonable amounts of fats and limited amounts of carbohydrates were based on results of research conducted in 1930 [ 2].

The discovery of antibiotics (penicillin, Alexander Fleming 1928) and its universal application as an effective and fast-acting medication against many diseases reduced interest of physicians, researchers, and patients in the associations between diet and symptoms of diseases. The issue of diets dedicated to inflammatory rheumatic diseases and other disorders captured the public's attention again in the 1980s and 1990s. It was discovered that there are certain benefits of changing nutritional habits for the treatment of inflammatory rheumatic diseases, particularly RA. They were associated with starvation diet limited to consumption of water only [ 3- 5], vegetable and fruit juices [ 6- 9], lactovegetarian diet (meat free, dairy consumption) [ 7, 9, 10], vegan diet (only plant derived foods) [ 10- 16], and other restrictive diets (eliminating specific nutrients) [ 17- 20].

Researchers of the 21 st century working on rheumatoid arthritis and related nutrition are mainly interested in two aspects:

In the age of the Internet, we searched the most-used database, PubMed, by using keywords such as: "nutrition", "diet", "vegetarian", "vegan", "fasting", "rheumatoid arthritis", "RA", and "rheumatic diseases" as single phrases and in any connection with: "nutrition in RA" and "diet in rheumatic diseases". We found and looked at around 200 papers published from the early 1980s to 2018 and selected ones that referred to food products, not only minerals, and rheumatic diseases. Eventually, we chose 39 mostly original papers. The research results were listed according to the food products being evaluated, and we compared conclusions. The aim of the article is to present the opinions of researchers on what products are considered to be important in increasing the risk of developing RA and those that affect the course of the disease.

Factors increasing rheumatoid arthritis incidence risk

Research papers that try to associate new cases of a disease with past behaviours usually focus on: smoking, alcohol consumption, and various nutrition habits such as using large amounts of salt, consumption of meat, and coffee or limited consumption of fruit and vegetables. The studies were conducted using different methods, which made it more difficult to compare their results. We used data from pre-existing results of population research and evaluated risk factors for RA incidence. It is essential that there is access to health registers that gather information such as prophylactic examinations and incidence of diseases.

It is possible to link pre-existing declared behaviours with RA incidence in countries that run medical registers and gather data on pro-health behaviours. We can then evaluate the influence of smoking, consumption of alcohol, coffee, or a diet on developing RA in the future. Such studies usually include at least one non-RA person with similar demographics for each RA-patient, to establish a control group [ 21- 24].

The consumption of the following products was used to evaluate their influence on subsequent development of RA: meat [ 23- 26], fish [ 21], coffee and tea [ 27- 29], dairy [ 5, 15, 24], fruit and vegetables [ 24], olive oil, and alcohol [ 22, 30]. Some studies on food products also focused on nutrition ingredients such as omega-3 acids, vitamins, and macro- and microelements [ 23, 25].

The studies conducted in different centres have not provided any consistent results about the influence of specific products on the development and course of RA. If the results are not contradictory and present positive influence or its lack, then we may assume that the evaluated product does not increase the risk of RA. If RA is already developed, we assume that it does not deteriorate its symptoms. Such results referred to research on consumption of: fish, fruit and vegetables, olive oil, and alcohol [ 21, 22, 24, 30, 31].

Based on earlier studies of eastern populations, Chinese researchers conducted a cross-sectional multicentre study in 2012-2013 to investigate associations between dietary intake and risk of RA. Study participants included patients diagnosed with RA and healthy volunteers.

The results indicated that among the Chinese population, higher intake of carbohydrates and lower intake of dairy products, mushrooms, and citrus fruits may be associated with a risk of RA development [ 24].

Alcohol

The 2009 the Swedish EIRA study (Epidemiological Investigation of Rheumatoid Arthritis) and the Danish CACORA study (Case-Control Study on Rheumatoid Arthritis) proved that limited amounts of alcohol decrease the risk of RA incidence. Both studies compared consumption of alcohol among RA patients against a control group of non-RA patients matched according to age, gender, and place of residence. The respondents were asked to evaluate their average weekly consumption of alcohol with the number of drinks consumed. One drink equalled 16 grams of alcohol. Then the respondents were divided into four groups: non-drinking, low alcohol consumption (lower or equal to the median), moderate consumption (above the median but lower than 75 th centile), and high consumption (over 75 th centile). Both groups were also genetically tested for the presence of HLA-DRB1 allele that increases predisposition for RA development [ 21, 30].

There was another Swedish study conducted in 2003-2009 with results published in 2012, which used data from the register of mammogram examinations and the register of RA patients. It included women born between 1914 and 1948, who took part in two surveys about alcohol consumption in 1987 and 1997. It defined a glass of alcoholic beverage equal to 15 grams of alcohol weekly (one drink equalled 500 ml of beer, 150 ml of wine, or 50 ml of liqueur) as a measure of alcohol consumption. The results indicated that consuming at least three drinks a week over a period of at least 10 years lowers the risk of RA incidence by half compared with non-drinkers [ 30].

Coffee and tea

Studies on coffee consumption brought inconsistent results, especially on decaffeinated coffee, either confirming a relation with RA incidence or its lack [ 27- 29]. The Iowa Women's Health Study (IWHS) evaluated the influence of caffeinated coffee, decaffeinated coffee, and tea consumption on the health of women with seropositive and seronegative RA [ 28]. The participants declared consumption of decaffeinated coffee, caffeinated coffee, and tea using the number of cups as a measure. The results indicated an increased risk of developing seropositive RA in the case of women drinking at least four cups of decaffeinated coffee a day. A similar amount of tea decreased the risk [ 28]. A study from Finland found a positive correlation between increased consumption of coffee and increased risk of seropositive RA incidence; however, no such relation was found in the case of seronegative RA [ 27]. The Nurses' Health Study (NHS), which referred to previous studies, evaluated the relation between coffee consumption and RA incidence. No relation was found [ 29].

Meat and meat products

Studies on how meat consumption influences RA have given inconsistent results [ 23- 26, 31]. The NHS examined the influence of plant-based proteins, animal proteins, and iron. The respondents declared their nutrition habits until the moment of first RA symptoms. No significant correlations were found between various amounts of meat and iron consumption and RA incidence [ 25]. The results of the European Prospective Investigation of Cancer in Norfolk (EPIC) showed that higher consumption of proteins, regardless of their origin, fosters inflammatory processes. Individuals consuming the highest amounts of meat (over 87.8 g/daily) had more than a doubled risk of developing an inflammatory rheumatic disease [ 23].

Sodium intake

In 2015 researchers from Umeå University in Sweden presented results suggesting that a diet rich in sodium coupled with smoking increases the risk of RA incidence. The study divided participants in three groups: smokers, ex-smokers, and non-smokers. Then they were divided into tertiles according to daily consumption of salt and the median for each tertile: low consumption - 1.51 g/daily, average - 1.88 g/daily, and high - 2.15 g/daily. Smokers and ex-smokers were qualified to the smokers' group. Thus, six groups were analysed: smokers and non-smokers within three different levels of sodium consumption. The amount of sodium consumed was calculated according to the declared consumption of meals in which salt was used. The study revealed that smoking together with high sodium consumption increases risk of developing RA [ 32].

The results of the study led to the conclusion that all products containing proteins (especially animal proteins) as well as arachidonic acid, salty fish, and cereal have the greatest influence on risk of developing RA.

Mediterranean diet

The interest in the Mediterranean diet as optimum nutrition for RA patients stemmed from the effect that it had on cardiovascular diseases. Studies on its positive impact on lowering incidence of cardiovascular diseases have been conducted since the 1960s. Some of the results include the pyramid of healthy nutrition based on the Mediterranean diet. Nowadays, the diet of Mediterranean region residents includes greater quantities of meat, and it is believed that the diet of Crete residents is the closest to the former model Mediterranean diet. The NHS (Nurses' Health Study) conducted in the United States in 1980-2008 and 1991-2009 aimed to find links between the Cretan Mediterranean diet and RA incidence among US female residents. The results were published in 2015. There were no statistically significant indications that a Mediterranean diet, considered a nutrition model, lowered the risk of RA incidence. Only a moderate alcohol consumption (5-9.9 g/daily) lowered the risk, whereas increased consumption of legumes increased the risk [ 33].

The impact of diet on disease symptoms

When the EULAR (European League Against Rheumatism) recommendations for treatment of early RA were being worked out, nine out of 14 participating rheumatologists were busy with issues of nutrition for RA. None of the existing studies has unequivocally proved an advantageous influence of specific diets on the course of the disease. The diversity of research in terms of assumptions, organisation, and its limited number were the reasons. However, it was observed that a vegetarian diet has positive influence on clinical variables, pain, and disease activity indicators. The recommendation for non-pharmacological support of RA treatment (Recommendation 11) says that there is not enough evidence to conclude that a vegetarian diet has an advantageous influence on the course of RA. However, physical activity is recommended [ 34].

A distinctive feature of the existing studies conducted among RA patients is the diverse influence of consumption of specific products on the development of seropositive (with RF rheumatoid factor) and seronegative (without rheumatoid factor) types and in the presence or absence of ACPA antibodies. Studies divide RA patients according to the presence of rheumatoid factor or ACPA antibodies. Usually, if there are differences in how consumed products influence the development of RA, they usually refer to patients with a rheumatoid factor and ACPA antibodies. In the case of RA patients without RF and ACPA antibodies, the influence of examined nutrients is not observed [ 21, 22, 28, 29].

Studies on how nutrition may influence a disease course usually assume a specific diet over time for one participant and recruiting another participant with similar qualities, who keeps using a traditional diet, to establish a control group. Usually, the influence of restrictive diets is examined (e.g. vegetarian or vegan diet) or diets considered as healthy (such as the Mediterranean diet).

The authors of the Brigham RA Sequential Study mailed a survey to 300 subjects from a single-centre RA registry asking about consumption of 20 foods that make their RA symptoms better, worse, or unchanged. Almost a quarter of them replied saying that foods do affect their RA symptoms. Out of the 20 products listed, blueberries and spinach were most often reported to improve RA symptoms, while soda with sugar and desserts were most often reported to worsen it [ 35].

A survey from Poland conducted in 2012 found that rheumatic disease was affected by diet among 60% of respondents. However, only 10-39% of them confirmed this in the case of specific food groups listed in the survey, with groats (39% of respondents) and oily fish (32%) being assigned a positive influence most often. The respondents declared that they felt worse only after consuming alcohol (47%) [ 36].

A literature review provides information about the influence of various types of vegetarian diets on symptoms of rheumatoid arthritis (RA) and other rheumatic diseases [ 9, 10, 14]. However, there are numerous methodological issues related to them: small sample size, short observation period, lack of a blind sample, and a large percentage of withdrawals from participants. The essential element of a vegetarian diet is elimination of certain animal source foods; however, different types of vegetarian diets eliminate different elements. For instance, a lactovegetarian diet includes dairy while a lactoovo vegetarian also eats eggs, and a pescovegetarian diets also adds fish. The most restrictive diet is veganism, which excludes all animal source foods (including milk and honey) [ 37- 39]. It is believed that a starvation diet for 7-10 days induces anti-inflammatory effects. Starvation is recommended prior to going on a vegetarian diet [ 3, 4, 6- 10, 16]. Recent research has revealed the benefits of starvation for an organism as a result of the cells' adaptive behaviour, which lowers the activity of inflammatory factors and optimises energy consumption [ 38].

However, the results of a Swedish study from 2002 indicate that a Mediterranean diet reduces disease symptoms. It included examination of 26 RA patients that were on a three-month Mediterranean diet and a group of 27 RA patients on their unchanged, regular diet. Both groups were evaluated for disease symptoms [ 40, 41].

The TOMORROW (Total management of risk factors in rheumatoid arthritis patients to lower morbidity and mortality) study being conducted in Japan since 2010 (planned until 2020) is attempting to identify the key elements of the Mediterranean diet responsible for improving RA symptoms. The already published part of the study included 208 RA patients and 205 healthy controls matched according to age and gender. The activity of a disease was measured with DAS-28 (assessment of 28 joints and ESR). The authors have concluded so far that daily consumption of monounsaturated fatty acids (part of a Mediterranean diet) may be responsible for improving RA symptoms [ 42].

Diets were also assessed in terms of their influence on risk of RA incidence, but no correlations were identified [ 32].

The researchers used different methods to minimise deviations among participants. They included ready-to-eat meals delivered to the home and a periodic stay in a resort serving food according to a specific nutrition program [ 10, 13].

The study conducted in Helsinki lasted three months and included 43 participants who were subjected to ambulatory treatment. Half of them had a special nutrition plan developed by a dietician while the control group's diet did not change. Despite the fact that participants from the first group had their meals delivered, as many as 10 out 22 did not comply with the nutrition guidelines that were assumed by researchers [ 13].

A study from Norway that aimed to evaluate the influence of starvation and a vegetarian diet on RA patients included 53 RA patients - 27 in the experimental group and 26 in the control group. Both groups spent four weeks of the experiment in centres where they consumed either vegetarian or traditional meals. During the following 3.5 months the experimental group members were on a gluten-free vegan diet by themselves and then on a lactoovo vegetarian diet (no meat with eggs and dairy allowed). The certainty about following the diet was limited only to the first four weeks spent in centres. The control tools during the remaining time of the experiment were limited to phone calls, taking notes, and ordering lab tests. A reduction in disease symptoms was observed among 44% of vegetarian diet followers. Return to a regular diet aggravated symptoms among 37% of respondents with RA. The results were published in 1991 [ 10].

A study from India, which tried to examine the influence of selected food products on disease symptoms, included 27 RA patients who did not use any medications aimed at affecting the course of disease. After a two-week diet excluding legumes, grains, milk, and plant proteins only 14 participants remained in the experiment. After another 10 months only three participants were still on the diet. Unlike other research, this study was not based on a restrictive diet but rather on adding products to a diet after cleansing the body. The initial diet that included vegetables, fruit, sugar, and refined oil was enhanced after two weeks by legumes and then by wheat or rice followed by dairy and then animal-sourced foods at the end: eggs, meat, and fish. The results revealed that patients do react to such modifications, but their reaction is different to different products. Out of 14 participants 10 (71%) experienced reduction in disease symptoms. The results were published in 1988 [ 11].

The tables present research results referring to nutrition and described in this paper. lists studies and factors that were evaluated and their influence on RA incidence. The population studies with large samples indicate that the RA prevalence rate is less than 1% among registered patients. This is consistent with the estimations from the World Health Organisation (WHO) [ 43]. lists studies and the influence of diets on disease symptoms. Such studies were usually done at the end of the twentieth century, whereas the incidence rate of RA was usually a subject of research in the 21 st century. Both tables exclude literature reviews [ 8, 12, 31, 34, 39], studies that included only a few participants and may be considered more like case studies [ 5, 6, 9, 14, 16, 20], and studies that evaluated effects of nutritional manipulation [ 11, 17, 18].

Table I

Table II

Study/Type of diet

Publication year

Number of participants

Study with control group

Mediterranean diet

Vegetarian diet

Vegan diet

Elementary diet

Periodical starvations

Conclusions

The reviewed studies that evaluated the influence of different diets and food products on increased RA incidence risk or, in the case of RA patients, on disease course and symptoms do not provide unequivocal answers to the question about recommended nutrition for RA patients.

The results indicate that moderate alcohol consumption lowers the risk of RA or reduces its symptoms. Attention should be paid to the European Society for Clinical Nutrition and Metabolism (ESPEN) recommendations appearing in the following years, which contain nutritional recommendations for chronic diseases such as: inflammatory bowel disease, lung diseases, or nutrition of the elderly or in the intensive care unit and others. ESPEN recommendations may also be a guide to dealing with patients with rheumatic diseases, including rheumatism [ 44].

Some studies analysed in the article suggest reducing consumption of carbohydrates (sugars) and proteins, especially ones of animal origin. The existing studies fail to deliver unequivocal results that would make it possible to define a diet recommended for RA patients. It is indicated though that consumption of fish, fruit, vegetables, and olive oil may help in reducing disease symptoms. The inconsistent results of research leave patients only with an ability to observe themselves and their reaction to different food products.

Footnotes

Financing of the work: the statutory program of the National Institute of Geriatrics, Rheumatology and Rehabilitation (S/23).

The authors declare no conflict of interest.

References

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The impact of nutrition and generally available products such as nicotine and alcohol on rheumatoid arthritis - review of the literature

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Nutrition habits and diet may influence disease development and course. There are no specific recommendations related to rheumatic diseases for a diet that would facilitate treatment. However, some research results suggest that various nutrients may affect the health of patients, especially in the case of inflammatory rheumatic disease such as rheumatoid arthritis (RA).

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Weight loss and improvements in fatigue in systemic lupus erythematosus: a controlled trial of a low glycaemic index diet versus a calorie restricted diet in patients treated with corticosteroids - PubMed (nih.gov)

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Weight loss and improvements in fatigue in systemic lupus erythematosus: a controlled trial of a low glycaemic index diet versus a calorie restricted diet in patients treated with corticosteroids - PubMed (nih.gov)

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The purpose of this study was to determine if different diets would result in flare ups and weight loss in lupus patients. The participants were all female, had a BMI >25 kg/m2 and had corticosteroid dependent lupus. This study is important because there can be concern amongst lupus patients for ways to lose weight through their diet without causing a flare up. Specifically, this study evaluated low GI and low-calorie diets. A key finding in this study was that both diets caused significant weight loss without flare ups and showed significant reduction in overall fatigue of patients. The clinical implications of this would be for providers to potentially recommend these diets to patients interested. While this study was not a very large group of participants, all of them found weight loss relief without exacerbating their lupus. This study provides options for patients to try with success from other patients which would likely provide some confidence in trying for fellow lupus patients.

Davies RJ, Lomer MC, Yeo SI, Avloniti K, Sangle SR, D'Cruz DP. Weight loss and improvements in fatigue in systemic lupus erythematosus: a controlled trial of a low glycemic index diet versus a calorie restricted diet in patients treated with corticosteroids. Lupus. 2012 May;21(6):649-55. doi: 10.1177/0961203312436854. Epub 2012 Feb 6. PMID: 22311939.

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👍 Mediterranean diet;  👎 Western Diet  for Multiple Sclerosis   

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👍 Mediterranean diet;  👎 Western Diet  for Multiple Sclerosis   

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The research paper selected for this week is titled: “The Role of Nutritional Lifestyle and Physical Activity in Multiple Sclerosis Pathogenesis and Management: A Narrative Review.”

This research paper is a 2021 review from the neurosciences department of the University of Palermo, Palermo, Italy.  They have reviewed the existing evidence on nutritional lifestyle and physical activity from the perspective of the Multiple Sclerosis (MS) management.  They have reviewed the diets, macronutrients, oligoelements associated with MS pathogenesis and clinical course.

This study is important because it reviews the nutritional lifestyles with the greatest association with the pathogenesis and improved clinical course for patients with MS.  The authors point out that a pro-inflammatory status associated with high-lipid diet, abdominal obesity and/or dysbiosis contribute to MS pathogenesis and severity.

The key findings from this study are that low-carbohydrate, Mediterranean, and fasting-mimicking diets have evidence in animal models and human studies positive effects on MS and have positive patient reported outcomes.

A clinical implication from of this study is that the Western diet is associated with the pathogenesis of MS and that deliberate nutritional lifestyle such as Mediterranean diet improve the clinical course of the disease.  1

1.          Fanara S, Aprile M, Iacono S, et al. The Role of Nutritional Lifestyle and Physical Activity in Multiple Sclerosis Pathogenesis and Management: A Narrative Review. Published online 2021. doi:10.3390/nu13113774

Richard Proudfoot

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Exercise Prescription for patients with MS- Ashley Wahlman

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Exercise Prescription for patients with MS- Ashley Wahlman

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For the weekly wall discussion, I decided to look at potential treatments for MS. As we know many patients with MS suffer with motor dysfunction due to muscle weakening, fatigue, spasticity and balance issues. As a result of this, many physicians wouldn't recommend any physical activity to newly diagnosed MS patients. However, regular physical activity in these patients has shown to have promising benefits. Such as limiting the deconditioning process and improving the patient back to optimal functioning including physical and mental health. One key finding is that they noticed by strengthening the respiratory muscles this enhanced maximal inspiratory and expiratory pressures. Which is very important because people who suffer with MS typically have a more difficult time breathing due to respiratory muscle weakness. I think this plays into nutritional sciences very easily. I always think that being healthy requires eating a more balanced diet as well as pairing that with exercise to achieve optimal results. Which is how exercise relates to nutritional sciences because eating healthy is one part of the equation and exercise is the other part. This has many implications because for a significant amount of time we wouldn't prescribe exercise to MS patients, but we continuously observed their physical and mental health decline. However, with tailoring exercise programs to each individual patient we have been able to observe the patient get back to a much better physical and mental health. Overall, I believe this is a great therapeutic recommendation it doesn't require the patient to take more medications that could possibly affect their health. Instead they can do something naturally that will have many positive benefits.

Halabchi, F., Alizadeh, Z., Sahraian, M. A., & Abolhasani, M. (2017). Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC neurology, 17(1), 185. https://doi.org/10.1186/s12883-017-0960-9

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Abstract

Background

Multiple sclerosis (MS) can result in significant mental and physical symptoms, specially muscle weakness, abnormal walking mechanics, balance problems, spasticity, fatigue, cognitive impairment and depression. Patients with MS frequently decrease physical activity due to the fear from worsening the symptoms and this can result in reconditioning.

Physicians now believe that regular exercise training is a potential solution for limiting the reconditioning process and achieving an optimal level of patient activities, functions and many physical and mental symptoms without any concern about triggering the onset or exacerbation of disease symptoms or relapse.

Main body

Appropriate exercise can cause noteworthy and important improvements in different areas of cardio respiratory fitness (Aerobic fitness), muscle strength, flexibility, balance, fatigue, cognition, quality of life and respiratory function in MS patients.

Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients affected by mild or moderate disability.

MS patients can positively adapt to resistance training which may result in improved fatigue and ambulation.

Flexibility exercises such as stretching the muscles may diminish spasticity and prevent future painful contractions. Balance exercises have beneficial effects on fall rates and better balance.

Some general guidelines exist for exercise recommendation in the MS population.

The individualized exercise program should be designed to address a patient's chief complaint, improve strength, endurance, balance, coordination, fatigue and so on.

An exercise staircase model has been proposed for exercise prescription and progression for a broad spectrum of MS patients.

Conclusion

Exercise should be considered as a safe and effective means of rehabilitation in MS patients. Existing evidence shows that a supervised and individualized exercise program may improve fitness, functional capacity and quality of life as well as modifiable impairments in MS patients.

Keywords: Multiple sclerosis, Exercise, Fitness, Balance, Fatigue

Background

MS or demyelinating disease of central nervous system is characterized with neurodegeneration, inflammation, axonal demyelination and transaction [ 1- 3].

This disease has a chronic nature and affects young people, especially women [ 3]. However, it can be identified in childhood or late adulthood, although this is rare [ 4- 6].

The chronic course of multiple sclerosis can result in significant mental and physical symptoms and irreversible neurologic deficits, including muscle weakness, ataxia, tremor, spasticity, paralysis, balance disorder, cognitive impairment, loss of vision, double vision, vertigo, impaired swallowing and speech, sensory deficits, bladder and bowel dysfunction, pain, fatigue, and depression [ 3- 5, 7].

Motor dysfunctions in MS patients are frequently due to muscle weakness, abnormal walking mechanics, balance problems, spasticity and fatigue [ 6, 8, 9].

MS has an unpredictable progressive nature and defects and restrictions of activities may suddenly occur and proceed further than the expected time [ 10].

It is reported that nearly 50% of multiple sclerosis patients use a an accessory device for moving following 15 years from the beginning of disease [ 11, 12]. Patients frequently reduce their activities due to their fear of symptoms exacerbation [ 13]. Limited activities increase disability,unfitness, mobility, quality of life (QOL),gait abnormalitiesand lack of stability and muscle strenght [ 14, 15].

Impairments related to the disease process itself are irreversible by exercise, but impairments resulting from deconditioning are often reversible with exercise [ 16]. Furthermore, inactivity places MS patients in raised possibility of comorbid health dependent conditions.

Hypercholesterolemia, hypertension, obesity, type 2 diabetes, cancer, arthritis, osteoporosis, depression, fatigue and death from cardiovascular diseases are the most frequently reported comorbid health -related conditions [ 13, 16].

These comorbidities in MS have further been connected with a raised possibility of inability development because of reduced aerobic capacity, decreased muscle strength, increased muscle atrophyas well as further neurologic risks (e.g., stroke, etc) [ 16].

For many years, physicians advised newly diagnosed persons with MS to avoid anyphysical activity and exercise. But now, we believe that regular exercise and training is a possible solution during disease period by limiting the deconditioning process and achieving an optimal level of patient activity, functions and many physical and mental health benefits without any concern about a triggering onset or exacerbation of disease symptoms or relapse [ 13, 16].

We review in this paper, therapeutic function of physical training in multiple sclerosis. The aim of this narrative review is to emphasize the current documents in exercise recommendation including aerobic, resistance, balance or combined trainingin MS patients, and to provide instructions for the sensible use of the physical modalities. Another aim is to outline the impacts of exercise on MS patients by summarizing the physiologic and health view of multiple sclerosis disease.

Part I

Physiological profile of MS patients

MS patients, especially with more severe impairments, may exhibit some differences in their physiological characteristics in comparison tohealthy age-matched people in terms of cardiovascular and muscle physiology [ 16].

Decreased aerobic capacity and cardiorespiratory fitness, in expression of VO ₂maxor maximal oxygen consumption, among MS patients has been about 30% lower than the healthy controls. Respiratory dysfunction due to respiratory muscle weakness and external causes like muscle defect and tiredness are contributing factors in reducing aerobic fitness [ 14, 16- 18].

Another cardiac factors such as basic heart rate and minimum blood pressure are noted to be increased in multiplesclerosis because of impairments in the autonomic control of cardiovascular function that has been estimated about 7% to 60% among MS patients [ 13, 19].

It must be shown that muscle strength defect appears particularly clear in the lower extrimities in comparison to the upper extrimities [ 8, 13].

Flexibility is another physiological characteristic that has diminished in MS patients specially in those with spasticity [ 16].

Benefits of exercise for MS patients

Appropriate exercise can lead to significant and important improvements in different areas of cardiorespiratory fitness (Aerobic fitness), muscle strength, flexibility, stability, tiredness, cognition, quality of life and respiratory function. At this section, the details of benefits are described [ 3].

Cardiorespiratory fitness

Aerobic training in MS patients is more extensively studied than resistance training. During aerobic training, the patients use multiple muscle acts opposite a low burdon with aim of increasing cardiovascular fitness [ 16].

In summary, aerobic training of low to moderate intensity is effective on cardiovascular fitness, mood and QOL(quality of life) in multiple sclerosis patients with EDSS < 7. This type of exercise is safe and tolerable in many individuals with MS. multiple sclerosis patients are shown to make favorable gains in cardiorespiratory fitness within a short term of exercise (for example, 4 weeks) [ 18, 24].

Cardiorespiratory exercise training in MS is associated with increased VO ₂ Max or VO ₂peak and working capacity, respiratory function and reduction of fatigue [ 18, 25].

A number of studies have made better in cardiorespiratory fitness and aerobic capacity in response to exercise interventions. For instance, Rampello et al. (2007) showed that cardiorespiratory training is better than neurorehabilitation in improvement of functional and moving capacity in multiple sclerosis patients with EDSS < 7 [ 26].

In another study, Swank et al. (2013) showed that structural cardiorespiratory training can cause improvement in quality of life and emotion of multiple sclerosis patients [ 2].

In addition cardiorespiratory training can can increase aerobic fitness and reduce tiredness in MS patients some degrees of disability [ 27]. However, it is not clear whether MS patients with sever impairements have similar adaptations to the cardiorespiratory training benefits or not [ 13].

Muscle strength and endurance

During strength training, the patients use muscle contractions against a load for increasing muscle strength. Some studies have demonstrated the benefits strenght exercises in MS patients [ 16, 28].

White et al. (2004) revealed the effects of the strenght exercise on leg strength, moving ability and self-reported fatigue and disability and showed significant improvements in knee extensor and plantar flexor muscle forces and thenwalking performance [ 8].

MS patients can make good adjustments to strenght trainings in accompanying by improvement in moving capacity and tiredness [ 30]. Gutierrez.et al. (2005) revealed that strenght training is a good intervention to improve moving and functional capacity in MS patients having moderate disabilities [ 9]. Surakka et al. (2004) reported that cardiorespiratory and strength training improves tiredness in MS patients with some degree of disabilities and the training type was more achievable in women patients with less disability in comparison to men patients with more disabilities [ 27]. In general, resistance training with moderate intensity can induce improvements in muscle strength and function among moderately impaired persons with MS. Thistype of exercise is safe and well tolerated in multiple sclerosis [ 8, 9, 16, 25, 29].

Bone health

The use of therapeutic corticosteroids and inactivity may both lead to osteoporosis and pathologic fractures in MS patients. Furthermore, the chronic process of disease and inactivity in multiple sclerosis patients can cause loss of muscle and bone mass. Shabas et al. (2000) showed that among 220 women with MS, 82% had corticosteroid's history of use and 53% had loss of mobility and bone mass [ 31].

Weight - bearing exercise can slow the loss of muscle and bone mass in MS. For this reason, the resistance training program is recommended for maintaining and developing the muscle and bone mass in the whole of body [ 18].

Flexibility

People with multiple sclerosis frequently have limitation in joint motion because of spasticity and prolonged inactivity. Goals of flexibility exercises are to lengthen the muscles, enhance joint range of motion, reduce spasticity, and maintain good posture and balance [ 16, 18].

Balance

Some articles showed the effects of balance training in stability of MS patients. Improvements in balance assessed by Berg Balance Scale (BBS), are shown following group aquatic and stability training [ 34, 35].

Cattaneo et al. (2007) studied the effects of stability training on multiplesclerosis patients and demonstrated that stability training is effective to reduce the falling and improve stability [ 36].

Generally, balance training has small, but statistically significant effect on improving stability and reducing falling risk in MS patients with some degrees of disabilities. There was limited data on patients with severe MS who are not ambulatory [ 33, 37].

Tiredness

Tiredness is greatly seen in MS patients and leads to exacerbation of the neurological and other symptoms of MS such as depression, pain, anxiety and cognitive dysfunction [ 18, 37]. The underlying mechanisms of fatigue are unknown.

Physical inactivity and mental disorders because of MS or comorbidities have been suggested to cause tiredness.

Exercise can cause some changes such as neuroprotection and neuroplasticity, reduction of long-term inactivityand deregulation of hypothalamus-pituitary- adrenal (HPA) axis and then reduction of tiredness in patients [ 38].

Kargarfard et al. (2012), revealed that aquatic training is effective on tierdness and QOL of women with MS [ 34].

Establishing a safe and effective exercise program may be considered as an important option while planning for treatment of fatigue and should be encouraged [ 37].

Quality of life

HRQOL(Health-related quality of life) has diminished in MS patients. The reduced QOL may be related with deterioration of symptoms, walking and cognition in patients [ 14].

In summary, exercise training can cause prominent and positive effects in QOL of persons with MS [ 3].

CNS morphology and imaging findings

Until now, no evidence has been foundabout the effects of exercise training on brain structure in multiple sclerosis disease. Any way, some studies revealed the effects of cardiorespiratory training on volume of brain grey matter volume and unity of white matter tract as well as functional connectivity of the hippocampus and cortex in people with MS [ 5, 45]. Despite the limited data on exercise performance on the brain structureon, some studies revealed regular cardiorespiratory training work against brain degeneration in relapsing-remitting type of MS and probably is a protective strategy.

Some studies proposed detection of morphological changes with exercise in the CNS of MS patients by imaging techniques. Although, evidence is still not enoughto demonstrate effects of exercise on brain structure in multiple sclerosis [ 46].

Implications for practice

The evidence confirms that individuals with MS are less active than healthy individuals [ 28]. This is important when designing effective exercise programs for both increasing the tendency and adherence to exercise and createing potential beneficial effects.

Part II: Exercise recommendations

Growing evidence exists in favour of exercise as an effective treatment for MS patients, and therefore it should be recommended in the rehabilitation process [ 7, 49].

Some general guidelines exist for exercise prescription in the MS population. In this part, we will discuss the practical points for exercise prescription in MS patients.

Pre-exercise evaluation

A comprehensive pre-exercise screening should be considered before designing an individualized exercise program. This should be preferably performed by sports medicine physician, physical medicine and rehabilitation physician, exercise physiologist or physical therapist with proper expertise on MS patients [ 13, 16, 18, 23, 50].

Also, some authors recommend fitness evaluations to be used as a baseline for exercise prescription in MS patients. Using these assessments, the physician can formulate an appropriate initial exercise program [ 53].

After medical clearance was obtained by physician, exercise professionals should use proper fitness tests to estimate the patient's cardiorespiratory, musculoskeletal fitness, as well as neuromuscular/functional competence [ 53]. These tests should be selected according to the patient's tolerance and goals [ 18, 54, 55]. Fitness tests should be performed according to the guidelines of American College of Sports Medicine [ 51]. The six minute walk test (6MWT) requiring minimal apparatus, is a valid tool for MS patients, and is applicable for patients who use walkers, canes, and assistive devices [ 56, 57]. Other proper tests consist of arm, leg, or combined leg and arm cycle ergometry and recumbent stepping.

Table describes suggestions for testing cardiorespiratory and musculoskeletal fitness, as well as neuromuscular/functional competence.

Table 1

Aerobic fitness

6-min walk test
It is used to measure improvements and differences in Pre and Post program performances but not to compare them to "healthy individuals."

Total distance walked, heart rate, RPE a, BP.
The HR response to exercise may be decreased due to autonomic dysfunction. Therefore, the use of the RPE scale is preferred in these patients.

Using air conditioner for all aerobic testing. Spasticity, lower limb weakness, and paralysis will preclude walking tests in some patients.

Submaximal, upright, or recumbent leg cycle ergometry. Intermittent instead of continuous protocol may be indicated. Increase work rate by 12-25 W per stage.

Workload and steady-state heart rate to predict VO ₂ peak; RPE.

Toe clips and foot straps may be necessary in persons with tremors, spasticity, or weakness in the lower extremities. Begin with a warm-up of unloaded pedaling or cranking.

Combination arm/leg cycle ergometry.

Workload and steady-state heart rate to predict VO ₂ peak; RPE.

May reduce difficulty in individuals with lower extremity uncoordination
Experience.

Arm ergometry-increase work rate 8-12 W per stage.

Workload and steady-state heart rate to predict VO ₂ peak;RPE.

Alternative for persons with lower extremity weakness or paralysis.

Muscular Strength/Endurance

30-s sit-to-stand test
These tests are used to measure improvements and differences in pre- and postprogram performance but not to compare them to "healthy individuals."

Number of times patient comes to a full stand with arms crossing a standard size chair.

A functional measure of lower extremity strength, power, and muscle endurance.

10RM Testing.

Maximal weight lifted for 10 repetitions (reps).

Machines provide test reliability, support, and joint stability. Remind patients to exhale on concentric action and avoid breath holding.

Flexibility

Modified bench sit and reach test (1 ft on floor and other straight).

Distance reached in hip/trunk flexion.

Administer test with client seated on a table.

Goniometry.

Range of motion.

Focus on flexibility of hamstrings, hip flexors, ankle plantar flexors, shoulder adductors, and internal rotators.

Power/functional

Timed up and go test.

Time to stand from a chair, walk a 3-m round trip, and sit back down on the same chair.

Results correlate with gait speed, balance, functional level, the ability to go out.

Five-times sit-to-stand test.

Time to stand and sit 5 consecutive times on a standard size chair.

Most useful in patients ≤60 y.

Exercise program

Exercise staircase model

An exercise staircase model has been proposed for exercise prescription and progression for a broad spectrum of MS patients [ 23].

At the base of the staircase is the passive range of motion exercises. This serves as the foundation and is suitable for the most physically and cognitively disabled. These exercises should be done no less than once daily.

The next step up the staircase is the active range of motion exercises. These are proper for less disabled MS individuals and may be carried out with or without gravity eliminationas strength allows. Even when diffused weakness exists, resistance exercises of cautiously chosen muscles, perhaps not more than 2 per limb, may still permit efficient strengthening. In motivated patients with mild MS, focused muscle strengthening with progressive resistive exercises may be effective.

The third and highest step in the staircase is integrated exercises. Integrated exercises use a combination of strength, endurance, flexibility, balance, and coordination exercises [ 16, 23]. Recent studies have also shown that combined exercisetraining may have advantages, especiallyin reducing fatigue perception, and improving someaspects of QOL [ 58, 59]. The exact combination of exercises should be individualized according to patient needs and capabilities. Aquatic exercise is a good example of an integrated exercise, simultaneously incorporating endurance, resistance, flexibility and balance components [ 16, 23].

Aerobic exercises

Bicycle ergometry, arm ergometry, arm-leg ergometry, aquatic exercise, and treadmill walking may all be suggested, although rowing and running are only recommended for MS patients with proper functioning [ 13, 54, 55, 60- 67]. Currently, the use of robot assisted weight supported treadmills has shown promising results in MS patients [ 68- 71]. Exercise frequency of 2-5 weekly sessions is recommended according to the patient's toleration. It is preferred to set these sessions in non-resistance training days [ 13, 53- 55]. Starting with intensity of 40%-70% of VO ₂max, 60%-80% of maximal heart rate or 40%-60% heart rate reserve is recommended [ 13, 18, 53, 63, 64]. A rating of percieved exertion (RPE) scale of 11-13 (fairly light to somewhat hard) is another valuable alternative for exercise intensity. As autonomic dysfunction (a common finding in MS patients) may attenuate the HR response to exercise in MS patients, the use of the RPE scale is advised throughout the exercise [ 13, 53- 55].

Depending on the level of patient's disability, the initial training duration of 10-40 min is suggested. At first, it may be splitted to three 10-min bouts [ 13, 53- 55]. During the first 2-6 months, progression should be attained by increasing the duration or frequency of exercise sessions. After this time, it should be checked to find out whether a higher intensity is tolerable. In this condition, one training session may be replaced with interval training (up to 90% of VO ₂max) [ 13, 18, 53- 55].

Resistance exercises

Training frequency of 2-3 weekly sessions is well tolerated and gives rise to significant progress in patients. Training intensity should be set in the range of 8 to 15 repetition maximum (RM) with 60%-80% of 1RM. Initial starting intensities of approximately 15 RM is suitable [ 53- 55]. This should be gradually increased over several months toward intensities of approximately 8 to 10 RM [ 8, 18]. Resistance can be securely added by 2% to 5% when 15 repetitions are properly carried out in successive training sessions [ 8, 18]. However, day-to-day variability in fatigue will likely justify flexibility in the resistance program. The rate of progression should permit for full recovery between exercise sessions to prevent overuse musculoskeletal injuries [ 13, 18].

The patient should begin with 1 to 3 sets, which can be gradually increased over a few months to 3 to 4 sets of each exercise. Allow rest breaks of 2 to 4 min between sets and exercises [ 16].

Regarding the number of exercises, a whole-body program including 4 to 10 exercises is suitable. As a general rule regarding the exercise order, large muscle group exercises should be performed before small muscle group exercises, and multiple-joint exercises before single-joint exercises [ 13, 53, 73]. Prioritize lower extremity over upper extremity exercises. In MS patients, the lower extremity strength deficit is greater than that of the upper extremity [ 13, 74].

Balance training of agonist/antagonist muscle groups is also necessary. Particular emphasis should be placed on the posterior shoulder girdle, spine, hip and knee extensors, and dorsiflexor muscles [ 4- 6, 9]. However, any contraindications based on individual impairments should be addressed [ 16, 18].

Sample exercises include shoulder press, seated scapular row, latissimus pull-downs, chest press, knee extensions, seated leg press, seated hamstring curls, biceps curls, seated triceps extensions, seated back extensions and abdominal crunches, and chair sit to stands [ 53- 55].

Flexibility and stretching exercises

Individuals with MS usually have limited range of motion as a result of spasticity and prolonged immobility. Flexibility exercises are recommended to lengthen muscles, offset the effects of spasticity, enhance joint mobility, and improve balance and posture [ 18]. These exercises should be performed at least daily for 10 to 15 min [ 18, 75, 76]. Stretching should be done before and after exercise sessions and must involve both upper and lower body muscle groups used in the program. The neck extensors, anterior shoulder girdle, hip flexors, hamstring, hip adductors and plantar flexors should be especially emphasized [ 53- 55]. Spastic muscles must be particularly targeted. Stretches should be slow, gentle, and prolonged. The stretch should be up to the end of the comfort range and held there for 20 to 60 s. Ballistic stretch or bouncing with the stretch is not recommended. Furthermore, stretching should not be painful. Individuals who need assistance with stretching may use a towel, rope, or partner. For immobilized patients with spasticity, passive stretching may be done by an expert therapist. Passive range of motion above the joint of a paralysed area is recommended. Complementary techniques such as deep breathing, light massage and progressive muscle relaxation techniques may also be beneficial. Supervized yoga or tai chi classes may be suitable for doing stretching exercises in higher-functioning MS patients [ 16, 18, 62].

Balance and coordination exercises

Particular attention should be paid to include activities for improvement of balance and coordination. In these activities, the MS patient should shift the centre of gravity and respond to external signals. Swiss ball exercise with coordinated movements and bilateral muscle actions may increase coordination and balance, as well. This type of exercise is extremely helpful to increase strength and flexibility, as well. Tai Chi exercises with slow eccentric movements may also be beneficial to maintain balance, strength and range of motion. For patients with insufficient stability or strength to take part in the mentioned activities, coordination and balance drills may be done in shallow pools. In this milieu, the risk of falling or injury due to balance loss is minimised and support of the water will permit the accomplishment of challenging movements, when it is not possible on land. Improvement of posture, flexibility, coordination and muscle tone are potential advantages of water exercise [ 6].

Respiratory muscle training

Adaptation of respiratory muscles to training programs can occur similar to skeletal muscles [ 18].

In a study, Foglio et al. (1994) examined respiratory muscle function and exercise capacity in MS patients. They concluded that in patients, reduction in exercise tolerance may be associated, at least partially, to diminished respiratory muscle strength [ 77].

O'Kroy et al. (1993) showed that respiratory muscle training enhanced maximal inspiratory and expiratory pressures, controlled breathing exercises and increased respiratory muscle endurance in MS patients. The use of ventilatory resistance training devices may be helpful and increase respiratory muscle strength [ 78].

Special precautions

MS patients are especially susceptible to exercise-related fatigue, heat intolerance, and falling [ 53- 55]. Furthermore, some problems such as spasticity, neurologic or cognitive deficits, and urinary incontinence may influence the exercise program. So, special measures should be considered in these cases. A summary of these precautions and safety recommendations are listed in Table .

Table 2

Special considerations

Precautions

Spasticity

Consider foot and/or hand straps for ergometers. Use machines instead of free weights [ 53- 55].

Cognitive deficits

Provide written instructions, diagrams, frequent instructions, and verbal cues [ 53- 55, 94]. Exercise tasks should be initially performed with minimal resistance. Individuals with cognitive impairments may require additional supervision during exercise to ensure their safety [ 18].

Higher energy cost of walking (2-3 times greater than age-matched healthy persons)

Adjust workloads to maintain target heart rate and check heart rate regularly [ 13, 53- 55, 94].

Daily variations in symptoms

Provide close exercise supervision and make daily modifications to exercise variables [ 13, 53- 55, 94].

Symptom exacerbation

Discontinue exercises and refer the patient to a physician. Resume exercise program.
Once symptoms are stable and the patient is medically ready to continue [ 13, 53- 56, 94].

Fatigue

Exercise on elliptical machine may result in significant reduction of fatigue among MS patients. So, this type of exercise may be a useful part of MS rehabilitation programs [ 80]. Aquatic exercise may also successfully improve fatigue of MS patients and may be considered in the rehabilitation of these patients [ 34].

Heat intolerance

A common concern with exercise in MS patients is potentially prompting Uhthoff phenomenon. Uhthoff phenomenon is defined as developing transient symptoms such as amblyopia or blurred vision triggered by overheating from exercise [ 6, 23]. The exact mechanism of Uhthoff phenomenon is not determined. It may be the result of heat-worsened conduction across partially demyelinated axons, fatigue of damaged neuronal pathways with repetitive nerve transmission, [ 23, 81] or a hormonal factor produced by cooling [ 16]. Exercise-induced Uhthoff phenomenon should not be considered as a contraindication for exercise [ 23]. Fortunately, temporary and mild heat stress causes only transient exacerbation of symptoms without apparent remaining impairment after normothermia is achieved [ 18]. It often settles within an hour or even sooner with rapid cooling [ 23]. Moreover, it is still more common in MS patients to respond to exercise in heat conditions with just general fatigue rather than Uhthoff phenomenon with focal neurologic deficits [ 23, 82]. Studies have demonstrated that usual exercise does not considerably increase core body temperature. A study reported a mean rectal temperature change of 0. C during land-based exercise and - 0.C during water-based exercise [ 83]. Alternatively, normal thermoregulatory responses (e.g., sweating and peripheral vasodilatation) that preserve a stable core temperature during usual exercise may be impaired in MS patients. In such cases, an increase in core temperature of even less than C may trigger heat-related symptoms [ 16, 23]. The use of cooling devices such as head-vest liquid cooling garment may provide some modest benefits for MS patients [ 84, 85]. Another study showed the reduced fatigue and improved ambulation for up to 3 h postcooling with the use of either the liquid cooling system or an icepack suit [ 23, 85, 86]. When engaging in pool-based aquatic exercises, the ideal water temperature for heat sensitive MS patients seems to be between 27 and 29 °C [ 18, 23, 87, 88]. Temperatures below 27 ° C can paradoxically enhance spasticity [ 23, 89].

Particularly for individuals with heat sensitivity, several investigators have recommended pre-exercise cooling strategies, such as the use of cooling devices, [ 6, 18, 50, 92] cold water lower body immersion, [ 18] or taking a tepid bath 20 to 30 min before (and after) exercise [ 23]. Individuals should wear light exercise clothing or may even try exercising with a cooling vest. The exercise area temperature should be kept cool through the use of fans or air conditioning [ 16, 23].

Risk of falling

Special attention is needed for patients at high risk of falling due to the balance and coordination problems as well as sensory and proprioceptive deficits. These issues should be particularly considered when planning and supervising exercise sessions in MS patients [ 13, 16].

Conclusion

Exercise should be considered as a safe and effective means of rehabilitation in MS patients. Existing evidence has shown that a supervised and individualized exercise program can improve physical fitness, functional capacity, quality of life and modifiable impairments in MS patients. There are general guidelines that may be followed for exercise prescription for the MS population. These guidelines should be adapted according to the patient's needs, abilities and preferences.

Acknowledgements

The authors would like to thank Development and Research center of Sina Hospital and Mrs. Pourmand (Urology Research Center, Tehran University of Medical Sciences) for editing the manuscript.

Funding

We did not have any sources of funding.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Authors' contributions

HF and AM Wrote the primary draft. SMA Proposed the idea and revised the primary draft. AZ reviewed the literature and approved the primary draft. All authors read and approved the final manuscript.

Notes

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

None of the authors had any financial or personal conflicts of interest.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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# data[].attributes.attachment_link.title
Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations

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Multiple sclerosis (MS) can result in significant mental and physical symptoms, specially muscle weakness, abnormal walking mechanics, balance problems, spasticity, fatigue, cognitive impairment and depression. Patients with MS frequently decrease physical activity due to the fear from worsening the symptoms and this can result in reconditioning.

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The role of diet in the treatment of rheumatoid arthritis

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The role of diet in the treatment of rheumatoid arthritis

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For this weeks module, I decided to look into a research paper that detailed the role of diet in the treatment of rheumatoid arthritis. I found this study to be very important because it directly relates to this course and this week's content. It gives great detail on what the illness and it's background. How RA is a chronic, inflammatory autoimmune disorder that affects the body's joints. This paper provides background to the disease by how it is characterized by severe inflammation of the synovial lining of the joints and provides key information about cytokines. This brings to light how much pain patient's who are diagnosed with this disease live their lives with.

One key finding to this study would be that some studies investigating the role of different dietary patterns in the treatment of RA have reported improvement in a number of symptoms, but the potential mechanisms of action are still unclear. In this study, they looked at Mediterranean diets, vegetarian diets, and elimination diets.

I would say the clinical implications of this study would be how clinicians could treat patients diagnosed with RA by altering their diet to improve their symptoms. If dietary alteration could be proven to improve conditions, they would be implemented clinically.

O’Connor, Á. “An Overview of the Role of Diet in the Treatment of Rheumatoid Arthritis: Diet and Rheumatoid Arthritis.” Nutrition bulletin 39.1 (2014): 74–88. Web.

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Abstract

Rheumatoid arthritis is the second most common form of arthritis that affects more than half a million adults in the UK. Medications can be used to relieve symptoms and/or help slow the progression of the disease, but some medicines have side effects and thus patients frequently turn to complimentary therapies including dietary modification. Studies of the effects of diet and nutrient supplementation on rheumatoid arthritis are hampered by study design issues (e.g. differences in the wide spectrum of clinical phenotypes among study participants). Despite this, there is good evidence to suggest that fish oil supplements may be helpful in relieving some symptoms, such as decreased morning stiffness, in those with long‐standing rheumatoid arthritis. Evidence relating to specialised diets, plant seed oils, antioxidants, minerals and trace elements, folate and other B‐vitamins, vitamin D and antioxidants are also considered in this paper. This paper provides a general overview of the scientific evidence of the role of specialised diets and nutrients in the treatment of rheumatoid arthritis.

References

Articles referenced by this article (88)

Bates B Lennox A Bates C et al 2012 National Diet and Nutrition Survey. Headline results from years 1,2 and 3 (combined) of the Rolling Programme (2008/09-2010/11) http://transparency.dh.gov.uk/2012/07/25/ndns-3-years-report/

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# data[].attributes.attachment_link.title
An overview of the role of diet in the treatment of rheumatoid arthritis

# data[].attributes.attachment_link.description
This website requires cookies, and the limited processing of your personal data in order to function. By using the site you are agreeing to this as outlined in our privacy notice and cookie policy. Rheumatoid arthritis is the second most common form of arthritis that affects more than half a million adults in the UK.

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Increased Cardiovascular Risk in Rheumatoid Arthritis

# data[].attributes.subject
Increased Cardiovascular Risk in Rheumatoid Arthritis

# data[].attributes.body
The paper I chose for this week's post focuses on rheumatoid arthritis(RA) related factors contributing to cardiovascular risk. As we just learned in this week's module, rheumatoid arthritis is an autoimmune systemic inflammatory disorder mostly affecting the destruction of the joints. Interestingly enough, while RA affects the joints, the largest proportion of excess mortality in rheumatoid arthritis patients is Cardiovascular disease, accounting for 39.6% of deaths. This can be explained by the increased TNF-α and IL-18 expression, as well as increased IL-33 and IL-33 ligand expression in RA patients. This finding suggests that this pro-inflammatory environment fosters atherogenesis; the process of plaque formation leading to coronary heart disease. This is important to understand because RA patients are at increased risk of cardiovascular disease. Several mechanisms beyond traditional cardiovascular risk factors confer this risk. Clinical treatment of RA patients needs to be aggressive against cardiovascular disease and continuous monitoring of risk factors is essential to reduce the substantial burden posed by this common comorbidity.

England, B. R., Thiele, G. M., Anderson, D. R., & Mikuls, T. R. (2018). Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications. BMJ (Clinical research ed.), 361, k1036. https://doi.org/10.1136/bmj.k1036