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ESPEN Guidelines for nutrition in Multiple Sclerosis

M3 India Newsdesk May 23, 2019


The ESPEN guideline recommends a diet lower in saturated fat and higher in polyunsaturated fatty acids with emphasis on the role of dietary vitamin D intake, prevention of obesity, and management of oropharyngeal dysphagia.

Neurological conditions are commonly associated with swallowing disorders and malnutrition. Oropharyngeal dysphagia, impaired consciousness, perception deficits and cognitive dysfunction are the major factors responsible for the development of malnutrition in patients with neurological diseases. These patients are at an increased risk of developing micronutrient deficiency and dehydration.

The European Society for Clinical Nutrition and Metabolism (ESPEN) guideline for clinical nutrition in neurology addresses clinical questions on best medical nutrition therapy in patients with neurological diseases. Herein we discuss the key recommendations from the guideline for managing clinical nutrition in multiple sclerosis.

Multiple sclerosis (MS) is a chronic disease, and weight loss, malnutrition and cachexia are some of the important characteristics of MS. Reduced mobility and fatigue, inappropriate diet, physical difficulty for eating or drinking, poor appetite, poor sight, reduced cognition and dysphagia are some of the reasons for malnutrition in MS; medical nutrition therapy should be catered on an individual basis after identifying the main cause of malnutrition.

Oropharyngeal dysphagia is one of the most severe complications of neurological diseases. In multiple sclerosis, dysphagia severely affects the nutritional status and occurs in more than one third of patients. Dysphagia is frequently accompanied with speech difficulties. Dysphagia also increases the risk for aspiration pneumonia and death particularly in the end stages of the disease. The management of oropharyngeal dysphagia thus plays a key role in the whole management strategy.

Role of diet in prevention of MS

Diet lower in saturated fat and higher in polyunsaturated fatty acids from food sources

For the prevention of MS, the experts recommend the intake of a diet lower in saturated fat and higher in polyunsaturated fatty acids from food sources. The use of n-3 fatty acids supplement for the prevention of MS is however, not suggested.

Various dietary patterns and dietary fats have been studied as a way to prevent the occurrence of MS. However, these studies have reported ambiguous results and the benefit from any specific diet have not yet been proven.

Dietary vitamin D intake and adequate sunlight exposure

The guideline recommends the intake of sufficient dietary vitamin D and adequate sunlight exposure for the prevention of MS. Dietary supplements can be taken in cases of low vitamin D intake and low sunlight exposure.

Epidemiological studies have suggested a link between MS incidence and sunlight and vitamin D3 levels - a finding that has been confirmed in observational and case–control studies. It has been hypothesised that MS is associated with low sunlight exposure or Vitamin D3 levels.

Vitamin B12 supplementation to prevent MS: Not recommended

Even though it is well established that vitamin B12 deficiency causes neurodegeneration, the hypothesis linking MS and vitamin B12 deficiency has not been confirmed. Subsequently, the authors do not recommend vitamin B12 supplementation as a way to prevent MS.

Vitamin C supplementation to prevent MS: Not recommended

The authors do not recommend vitamin C supplementation for MS prevention.

The antioxidant properties of ascorbic acid is a well-known fact, however, the benefits of high levels of vitamin C intake for neurodegenerative conditions have not been proved.

Gluten free diet to prevent MS: Not recommended

A gluten free diet in order to prevent MS is not recommended by the guideline.

There have been reports of similarities between brain magnetic resonance imaging (MRI) results of MS and celiac disease. This led to the belief that gluten hypersensitivity may led to MS. However, this hypothesis was counteracted by studies which found that neither the anti-gliadin antibodies nor morphological changes were found in the gut mucosa of patients with MS. Additionally, a gluten free diet was not found to have any significant positive effect MS patients.

Prevention of obesity in adolescence and early adulthood

Obesity during adolescence and early adulthood may increase the risk of development MS. The Nurses' Health Studies, published in Neurology in 2009, reported that women who were obese at the age of 18 had a two-fold increased risk of developing MS compared to women with BMI between 18.5 and 20.9 kg/m2. The authors thus recommend the prevention of obesity in this age-group for the prevention of MS.

Medical nutrition therapy and relapses in MS patients

Vitamin D therapy in MS patients

Vitamin D is said to be involved in immunomodulatory effects, increases lymphocyte proliferation and reduce the synthesis of pro-inflammatory cytokines. However, there is no clinical evidence on the effects vitamin D therapy on the relapse rate of patients with MS.

Supplementation with omega-3 and omega-6 fatty acids

The guideline does not recommend omega-3 fatty acids supplementation to decrease the number and severity of MS relapses. The authors however advocate that supplementation with omega-6 fatty acids could be of some benefit.

Clinical trials of PUFA supplementation in patients with MS have provided mixed results and had many limitations with regard to the trial design and study outcomes. A per a Cochrane review published in 2012 by Farinotti M et al., PUFAs had no major effect on the main clinical outcome in MS, but they may tend to reduce the frequency of relapses over two years.

Role of medical nutrition therapy in improving nutritional status in MS patients

The guideline recommends early detection and treatment of the causes of malnutrition in MS patients by a multidisciplinary team comprising of a neurologist, a nutritionist/dietician and a speech/language therapist. Screening and assessment of the nutritional status of the patients with MS with appropriate tools is also warranted.

Provisions for dietary advice for the prevention and treatment of nutritional problems in patients with MS are strongly recommended by the authors. Oral nutritional supplements can be considered in patients unable to meet their nutritional needs by diet.

Role of medical nutrition therapy in improving survival in MS patients

There is no direct evidence about the effect of medical nutrition therapy on survival of malnourished MS patients and more research is needed in this area.

Specific methods for screening and clinical diagnosis of OD in MS

There is lack of evidence to recommend one specific screening method for dysphagia.

MS patients should be screened for dysphagia early in the course of the disease and the screening should be repeated at regular intervals based on clinical situation. The patients should be routinely screened over the course of the disease. Instrumental exploration of dysphagia should be performed in patients with high risk for dysphagia, such as those with severe disabilities, cerebellar dysfunction and long disease duration.

Behavioural, rheological and rehabilitation treatments for OD in patients with MS

There are no specific recommendations for behavioural treatment of dysphagia and general recommendations for dysphagic patients should be followed.

Modified consistency foods and fluids can be used to ensure safe swallowing. Enteral nutrition (EN) therapy can be used in patients unable to cover their nutritional needs orally. PEG should be chosen as a method of delivery of EN.

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