December 15, 2011 — Regularly eating fish and drinking alcohol and coffee may help delay disease progression in patients with relapsing-onset multiple sclerosis (MS), a new study suggests.
However, consumption of these food items does not seem to affect disease development in patients with progressive-onset MS, the researchers found.
"Factors such as coffee and alcohol consumption could affect inflammation in relapsing-onset MS," lead author M.B. D'hooghe, MD, PhD candidate, a neurologist at the National MS Center, Melsbroek, Belgium, told Medscape Medical News.
"We should examine these factors in inflammatory models to see whether we can modulate the disease."
Because this is not an interventional study, its results cannot be used to make any dietary recommendations, although physicians should continue to encourage patients with MS to eat a healthy diet, said Dr. D'hooghe.
The study was published online November 25 in the European Journal of Neurology.
The study included data from 1372 patients with MS registered by the Flemish MS Society who completed questionnaires that collected information on demographics; MS characteristics; consumption of alcohol, wine, coffee, tea, and fish; and cigarette smoking.
Researchers classified alcoholic beverages by intake levels: no drinking; less than 1 drink weekly, 1 to 7 drinks weekly, and 2 or more drinks daily (because of small numbers, the researchers collapsed the heavier-drinking data into the moderate category). Categories of coffee and tea consumption were no drinking, occasional drinking, and daily drinking. Smoking categories included nonsmoking, occasional smoking, and daily smoking, and fish intake was categorized into less than once monthly, once monthly to once weekly, and 2 or more times weekly.
To assess disability, patients were asked to select from a series of statements describing limitations and walking disability. This allowed researchers to categorize participants into 11 levels of disability, from 0 to 10, corresponding to an Expanded Disability Status Scale (EDSS) score.
An EDSS score of 6 was used as a "milestone" measure for progressive disability, said Dr. D'hooghe. "Our outcome measure was the time to need some support to walk."
Almost 35% of the patients reported a progressive-onset disease. More than half (51%) had reached at least EDSS 6 after a mean disease duration of 19.7 years.
The researchers found that in relapsing MS, consumption of alcohol, wine, coffee, and fish (fat or lean) was associated with a reduced time to reach EDSS 6.
For example, the hazard ratio (HR) to reach that level of disability for moderate alcoholic drinking compared with no alcoholic beverages was 0.61 (95% confidence interval [CI], 0.46 - 0.80), and for moderate wine drinking it was 0.67 (95% CI, 0.50 - 0.89).
For occasional coffee intake, the HR for reaching EDSS 6 was 0.67 (95% CI, 0.46 - 0.97), and for daily coffee drinking it was 0.60 (95% CI, 0.44 - 0.81) compared with never drinking coffee.
Eating fish 2 or more times a week had an HR for time to sustained EDSS 6 of 0.60 (95% CI, 0.41 - 0.87).
"For patients who said that they never used these substances, there was a shorter time in reaching this milestone compared with patients who reported using them more frequently," said Dr. D'hooghe. "However, this was only the case in patients with relapsing MS."
The analysis suggested a dose-related effect for coffee, fish, and alcohol, but since there was a fair amount of overlap, this should be interpreted with caution, said Dr. D'hooghe. The results should not be viewed as support for drinking more alcohol, she added.
Smoking was associated with an increased risk to reach EDSS 6 in relapsing-onset MS.
For progressive-onset MS, consumption of alcoholic beverages, wine, coffee, tea, and fish, as well as smoking, did not significantly affect the time to reach EDSS 6. However, preference for fatty fish (eg, mackerel, tuna, salmon) compared with preference for lean fish was associated with an increased risk to reach EDSS 6 (HR, 1.56; 95% CI, 1.12 - 2.17).
"We found that fatty fish may be associated with worse outcome" in these patients, said Dr. D'hooghe. "We can only speculate that this may be due to contaminants in fatty fish," she noted, such as mercury and polychlorinated biphenyls.
Consumption of tea, which contains high concentrations of polyphenols and other anti-inflammatory compounds, did not affect the time to reach EDSS 6. According to Dr. D'hooghe, this may be because only a small number of respondents reported drinking large amounts of tea.
The study seems to suggest that the 2 types of MS have different underlying mechanisms, said Dr. D'hooghe. "Inflammation is playing a role in relapses, which are inflammatory demyelinating events, whereas progressive disease is due to axonal degeneration, and this may have something to do with problems with energy supply of the neurons and the axons."
The fact that these associations are limited to relapsing-onset MS suggests that they are more than reverse causality — that it is not just driven by people with rapidly progressing disease changing their consumption habits related to coffee, alcohol, and fish — said Dr. D'hooghe. She noted experimental models that show the anti-inflammatory effects of alcohol in other disease, including rheumatoid arthritis.
Reinforce the Message
Approached for comment, Anthony Reder, MD, professor of neurology at the University of Chicago, Illinois, and member of the American Academy of Neurology, said the study reinforces what he has been telling patients for years: stop smoking, drink moderately, and eat a healthy diet. "This is really important, that lifestyle and diet can affect the course of MS," he said.
He said he was impressed with the study because of its design and the strength of the correlations, and for its ability to show "an actual delay in the time to a hard marker"; that is, using a cane to walk a certain distance.
"When you're at [EDSS] 6, it's usually progressive at that point," he said. "The key thing in MS is the transmission from relapsing remitting to progressive. Once that happens, the disease seems to become inexorably worse."
He agreed that the 2 types of MS could represent different kinds of immunity, and that each might respond to different therapeutic approaches. "Early on, it's more T cell–mediated — activation and suppression with these attacks — and that type of inflammation seems to be most noticeably affected by all our therapies, including interferons," said Dr. Reder. He added that research shows that interferon may delay transmission from relapsing to progressive MS by as much as 8 years.
In chronic forms of MS, "the damage has been done, and compromised neurons are still dying slowly. It's like premature aging," said Dr. Reder. 'Plus, there are macrophages in the brain that are slowly eating away at the brain cells."
Although the study population may not have been representative, patients were relatively old and had relatively severe disease. "This is the group you want to study, because they have some history," said Dr. Reder.
With regard to cigarette smoking, the findings "tie in with other literature" that found that smokers have 60% more relapses and that smoking about doubles the rate of brain atrophy. "I'm at the point where I tell patients that if they stop smoking, it may be as effective as starting a therapy," said Dr. Reder.
Although he said he does not push alcohol, patients with MS having occasional drinks is okay, and coffee may have anti-inflammatory effects, "which is important in an immune-mediated disease like MS," he said.
Dr. Reder thought the numbers were too small to draw any real conclusions about the effect of fatty fish on progressive onset MS.
For her part, Lily Jung Henson, MD, a neurologist at Swedish Medical Center, Seattle, Washington, found the study "fascinating."
"Obviously there are more questions than answers, as usual, but it's interesting in that it suggests that dietary modification may make a difference in terms of how one's MS evolves," she told Medscape Medical News.
The authors have disclosed no relevant financial relationships.
Eur J Neurol. Published online November 25, 2011. Full text
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