MULTIPLE SCLEROSIS

BY: WENDY BARTH AND ALLY ROBERTS

BACKGROUND

 Immune-mediated disease
characterized by the destruction of
myelin sheath and the formation of
scar tissue
 Destruction results in the
distortion or interruption of nerve
impulses
 Progressive disease
ETIOLOGY OF MS

 Exact cause of MS has not been established.

 Major areas of study include: genetics and environmental factors
 Several studies have supported a relationship between sunlight exposure and lower
MS risk
 Some have proposed that lower Vitamin D levels could be involved in the
development of MS
 No study or trial has yet to establish whether or not Vitamin D supplementation
reduces risk of MS.
SIGNS AND SYMPTOMS SPECIFIC TO MS

 Any nerve can be affected in MS—symptoms vary widely

 Numbness, tingling, uncoordination, and weakness are all common symptoms
 Some individuals experience visual problems such as double vision, blurred vision, or
blindness
 Other symptoms can include difficulty swallowing, constipation, and bladder
dysfunction
 Important to remember some patients experience a rapid progression, while others
have periods of remission and relapse
RISK FACTORS

 Age—commonly affects people between ages of 20 and 50

 Gender—women are twice as likely as men to develop MS
 Family History
 Certain Infections such as Epstein-Barr (virus that causes Mono)
 Climate—MS is more common in Canada, Europe, and Northern U.S.
 Smoking—more likely to develop a second relapse after experiencing an initial event
of symptoms
HOW IS MS DIAGNOSED?

 No single diagnostic test for MS

 Definitive diagnosis is not always possible due to
highly variable symptoms
 The McDonald criteria for diagnosis were revised in
2005—these criteria include:
 Clinical evaluation of the patient
 MRI
 Analysis of cerebrospinal fluid
DIFFERENT
TYPES OF MS
 Our client has RRMS
CASE STUDY: INTRODUCTION OF PATIENT

 Client, 34 yr old, white female diagnosed with RRMS (Mild MS)

 Stay-at-home mom w/ 3 boys; married
 Diagnosed with demyelination at age 20
 (MRI showed one spot on the brain)
 Most resent diagnosis: Multiple Sclerosis at age 26
 (MRI showed progression of disease; multiple spots)
 Hasn’t seen a doctor for MS after last diagnosis
CASE STUDY
 Patient History
 Signs & Symptoms: feeling of a surge of electricity if she looked down at her feet (Lhermitte’s Sign).
 her hands were tingling all the time, a lot during finals week of that year, almost 24/7.
 She also experienced issues with spasticity.
 Went in for first doctor appointment at age 20
 Ordered MRI --> result determined she had demyelination (spot found at C1)
 Was put on steroids to try and stop the demyelination
 Went in for second appointment in June of 2010 (age 26)
 Second MRI showed little spots on her brain

 Officially diagnosed with RRMS (Relapsing-Remitting multiple sclerosis)

PATIENT CASE STUDY- NUTRITION ASSESSMENT

 Anthropometrics
 Height: 5'7'  Medical Tests & Procedures
 Weight: 165#  Initial MRI and diagnosis MRI

 BMI: 26 (overweight classification)  Nutrition focused physical findings

 Biochemical  Good appetite, states "I love to eat!"

 Increased CSF  Enjoys cooking and preparing food

 Low serum vitamin D concentrations  Appears to be a well-nourished, content individual

 Very mobile
 No difficulty with chewing or swallowing
PATIENT CASE STUDY- NUTRITION
ASSESSMENT
 Food and Nutrition Related History
 Avoids: dairy, gluten, eggs, non-organic soy products, processed meats, most
oils and all saturated/ trans fats, sweets or artificial sweeteners, MSG, do not
use microwave for foods consumed.
 Preferences: Whole fat foods, bone broths, organ meats, wild game, cod liver
oil, omega-3 rich fish, kombucha tea
 Medications/ Nutritional Supplements
 Plexus ProBio 5 & Bio Cleanse, D3 5000 mg, PhytoMulti, Cod Liver Oil
 USUAL DIETARY INTAKE

Wake up (7:45am) - Starts her day with drinking a quart of water

Breakfast (8:30am) - 1 fruit choice (grapefruit, banana, apple) or hand full of nuts

-------- Works out (9:00-10:00am) ----------- ( 3-4 days a week)

Post-workout snack: Protein shake (2 scoops Vital Protein- Her Amino's w/ coffee and added berries

Lunch (11:00-Noon) - BIG SALAD (romaine lettuce, sliced carrots, cucumbers, mushroom, nori seaweed, sunflower
seeds, and blackberries w/ 2 Tbsp. Tessene dairy-free, organic, creamy ranch; 1 quart of water

Snack (3:00pm) - Fruit smoothie (apple, coconut milk, strawberries, blueberries, and/ or ½ banana)

Dinner (5:00-6:00pm) - ½ c pork sausage w/ ½ c spaghetti sauce, and ½ gogo quinoa w/ 1 quart of water

**Also likes to add Kombucha to daily fluid intake (blackberry ginger) 1 pint
PATIENT CASE STUDY- NUTRITION ASSESSMENT CONT.

 Comparative Standards
 Recommended calorie needs: 1800-2300 kcals/ day (25-30 kcals/ kg BW)
 Recommended protein needs: 60-75 grams protein/day (0.8-1.0 g/ kg BW)
 Recommended fluid intake: 1900-2300 cc/day (1 cc/kcal)
 Assessment of current intake
 Consumes 1600-1800 kcals/ day
 Eats mostly raw, organic, dairy-free, gluten free diet "paleo diet"
 Adequate in vegetable and fruit intake; on lower end in protein and grains; doesn’t consume dairy
 Nutrient analysis: Under in calcium, potassium, iron, vitamin D, vitamin E, and choline
PATIENT CASE STUDY- NUTRITIONAL DIAGNOSIS

 PES Statements
 Inadequate mineral intake (calcium) r/t dietary restriction of dairy AEB dietary recall and nutrient
analysis.
 Food- and nutrition related knowledge deficit r/t adhering to specific diet/ restrictions AEB dietary recall,
low vitamin E, calcium, potassium, iron, and choline concentrations.

 Other Common Nutrition Diagnosis

 •Inadequate or excessive intake, difficulty eating and preparing food, food-medication interactions
PATIENT CASE STUDY- NUTRITION INTERVENTION

 Nutrition Prescription
 RD recommends client consume 1,000 mg calcium a day either through dietary sources or
nutritional supplements.
 RD provided Nutrition Education & Counseling on:
 Consequences of restricting whole food groups/ foods from diet and how it affects her nutrient
intake and the importance of getting adequate vitamin D and calcium in her diet to support overall
health and strength. RD also discussed different dietary sources of calcium to help ensure adequate
intake.
COMMON EDUCATION AND COUNSELING FOR MS

 Encourage physical activity and how to control energy intake

 Discuss the role of fat and vitamin E in myelin sheath formation and maintenance, and where to find sources of
linoleic acid and omega-3 fatty acids from the diet.
 Provide tips on healthfully lowering salt intake. Encourage use of herbs and spices.
 Teach the patient/ client about foods high in fiber.
 Encourage moderate exposure to sunlight for vitamin D.
 Use tabletop cooking methods and equipment to avoid lifting. Utensils with large handles may be useful in food
preparation and self-feeding.
 Avoid smoking.
PATIENT CASE STUDY- MONITOR & EVALUATION

 RD will follow-up with client in 1-2 months assessing dietary intake, ensuring
adequate consumption of micronutrients.
CONCLUSION OF
MULTIPLE SCLEROSIS
TREATMENT OF MS
 No cure for MS, but
treatment involving a
variety of disease-
modifying medications can
reduce the frequency and
severity of relapses, slow
lesion development, and
slow the overall course of
MS.
 Drug-nutrient interactions
are can be common
 SOCIAL & PHYSIOLOGICAL IMPLICATIONS

 Depression
 Anhedonia
 Feelings of worthlessness or excessive gilt
 Significant increase or decrees in appetite with weight gain or loss
 Change in sleep patterns
 fatigue
 Mood disorders
 Anxiety
 Cognitive Dysfunction
 Isolation from peers (embarrassment)
CURRENT RESEARCH

 Polyunsaturated fatty acids (PUFAS) may reduce the frequency of relapses (Farinotti et al,
2012). Small clinical trial suggest a modest reduction in the severity and duration of relapses
in patients with MS receiving PUFA supplements (von Geldern and Mowry, 2012). Study
suggested use canola, olive, and fish oils regularly.

 Cannabinoids are potent immunosuppressive and anti-inflammatory agents. They affect

apoptosis, and suppress cytokine and chemokine production (Rieder et al, 2010). The
cannabinoid Sativex has been used for alleviating spasticity.
TAKE-AWAY SUMMARY
 As an RD remember/ address:
 Maximizing nutritional intake
 Limiting salt intake may help
 Anti-inflammatory diet- Mediterranean, MUFAs/ PUFAs
 Limit fatigue at meal times
 Evaluate nutrient intake- especially vitamin D and calcium
 Evaluate neurologic deficits and dysphagia progresses
 Neurogenic bowel: increase fiber and fluids for constipation and diarrhea
 Medication side effects – monitor
 Challenges to meal preparation (may need consistency modifications for chewing/ swallowing)
 Monitor CAM
 Encourage physical activity
REFERENCES

 Diet and Exercise. (2018, April 23). Retrieved April 30, 2018, from https://www.nationalmssociety.org/
 Escott-Stump, S. (2015). Nutrition and diagnosis-related care (8th ed.). Philadelphia: Wolters Kluwer.
 Nelms, M. N., Sucher, K., & Lacey, K. (2016). Nutrition therapy and pathophysiology(3rd ed.). Boston, MA: Cengage
Learning.
 Farinotti M, et al. Dietary interventions for multiple sclerosis. Cochrane Database Syst Rev. 2012 Dec
12;12:CD004192
 Rieder SA, et al. Cannabinoid-induced apoptosis in immune cells as a pathway to immunosuppression.
Immunobiology. 2010;215:598.
 The Psychological Impact of MS with Amy Sullivan, PSY.D. (n.d.). Retrieved from
https://my.clevelandclinic.org/health/transcripts/psychological-impact-of-multiple-sclerosis
 Von Geldern G, Mowry EM. The influence of nutritional factors on the prognosis of multiple sclerosis. Nat Rev
Neurol. 2012;8:678.