Essential Fatty Acid Supplements
Studies have shown that by adding polyunsaturated fats to the diet in the form of an omega-6 fatty acid, linoleic acid, there is a tendency towards slower progression of MS, but the results were a little inconclusive. These were three formal randomised controlled trials, all of them poorly set up.1-3 None cut down the patients’ intake of saturated fat and the control groups did not really take an inactive substance. They were given oleic acid, or olive oil. Olive oil has been shown to reduce the severity of experimental autoimmune encephalomyelitis (EAE), an animal model of MS.4 The numbers were too small in each individual study to get a statistically significant effect. So, a group of investigators pooled the results and looked at the overall effect, allowing for some differences between the studies.5 They showed a statistically significant decrease in the rate of deterioration with linoleic acid supplementation for those with minimal or no disability at entry to the study.
Recently, the UK National Health Service National Institute for Health and Clinical Excellence (NICE) produced guidelines for doctors managing multiple sclerosis http://guidance.nice.org.uk/CG8. This set of consensus guidelines from experts in MS summarizes all the available evidence on therapies in MS and makes recommendations for doctors to follow. They recommend that ‘people with MS should be advised that linoleic acid 17-23g/day may reduce progression of disability’.6 For people who are told by healthcare workers that diet has no role in the treatment of MS, it may be a good idea to refer them to these guidelines.
A trial by FitzGerald and co-workers in 1987 looked at the effects of nutritional counselling on outcome from MS.7These investigators were working on behalf of a group called ARMS, Action for Research into Multiple Sclerosis. The group was formed by a number of patients with MS who were distressed about the lack of available therapies offered to them after diagnosis. Judy Graham, who wrote the excellent book Multiple Sclerosis: A Self-Help Guide to its Management,8 was one of them. They approached a group of researchers at the Central Middlesex Hospital in London, hoping to further research the disease, and come up with some therapies. Their thrust was dietary. Professor Michael Crawford, Professor of Nutrition at Nottingham University, devised a diet which was high in essential fatty acids, and provided good intake of vitamins and minerals.
200 people with MS entered the study. There was a high dropout rate as the diet, testing and analyses were quite rigorous. Eighty-three remained in the study for 34 months. They were counselled to decrease saturated fat intake and increase polyunsaturated fats, as well as increasing antioxidants. For those that complied with the recommendations, as judged by rigorous dietary analysis, there was no significant deterioration in disability; for the poor dieters, the disability worsened. The p value was <0.022. The investigators proved that the good dieters did modify their diet by monitoring levels of the fats in the blood.
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A trial by FitzGerald and co-workers in 1987 looked at the effects of nutritional counselling on outcome from MS.7These investigators were working on behalf of a group called ARMS, Action for Research into Multiple Sclerosis. The group was formed by a number of patients with MS who were distressed about the lack of available therapies offered to them after diagnosis. Judy Graham, who wrote the excellent book Multiple Sclerosis: A Self-Help Guide to its Management,8 was one of them. They approached a group of researchers at the Central Middlesex Hospital in London, hoping to further research the disease, and come up with some therapies. Their thrust was dietary. Professor Michael Crawford, Professor of Nutrition at Nottingham University, devised a diet which was high in essential fatty acids, and provided good intake of vitamins and minerals.
200 people with MS entered the study. There was a high dropout rate as the diet, testing and analyses were quite rigorous. Eighty-three remained in the study for 34 months. They were counselled to decrease saturated fat intake and increase polyunsaturated fats, as well as increasing antioxidants. For those that complied with the recommendations, as judged by rigorous dietary analysis, there was no significant deterioration in disability; for the poor dieters, the disability worsened. The p value was <0.022. The investigators proved that the good dieters did modify their diet by monitoring levels of the fats in the blood.
Omega-3 versus Omega-6 Fatty Acids
These studies looked at omega-6 supplementation. We now know that omega-3 fatty acids work to suppress immune system disorders and omega-6s seem to worsen them, although not nearly as much as saturated fats. Additionally we have good evidence that MS is infrequent in places where fish (high in omega-3s) is eaten a lot. Japan for instance has a very low incidence. Perhaps omega-3 supplementation would be a better way to go than omega-6.
Some of the same investigators who had done the omega-6 work decided to do an RCT to test this.9 One of the difficulties was patient numbers, but also the investigators felt they couldn’t ethically use a placebo inactive treatment, as omega-6s had already been shown to work. So the control group took omega-6s. Once again there was no strict avoidance of animal fats; rather the patients were ‘given dietary advice to encourage a low intake of animal fat and a plentiful intake of omega-6 fatty acids’. So we have no record of how much animal fat patients in each group had, and the untreated group were actually receiving treatment with omega-6 fatty acids, which had previously been shown to work in MS. So were the group treated with the omega-3 fatty acids.
Not surprisingly the investigators failed to find a statistically significant difference. If omega-3s were better, you would expect both groups to get better, but the omega-3 group to be ahead. This is what they found: The omega-3 group did better; 79 patients were unchanged or better and 66 were worse at two years. Of the omega-6 group, 65 were the same or better, and 82 were worse. The p value for this difference was 0.07, not quite making the usual 0.05 accepted significance level. Although the researchers were ethically right in not asking the control group patients to miss out on the benefits of dietary changes, this decision almost certainly cost them the chance to get a p value which would be regarded as ‘proof’ by doctors in general.
The first RCT of diet in MS mentioned in the Dietary Fats in MS section found a statistically significant improvement in the group which took fish oil, with a reduction in relapse rate of 0.8 relapses per year.10 A Dutch review in 2005 concluded that fish oil may be beneficial in MS both through its immune mechanism of action and through structural effects within the CNS.11
Some of the same investigators who had done the omega-6 work decided to do an RCT to test this.9 One of the difficulties was patient numbers, but also the investigators felt they couldn’t ethically use a placebo inactive treatment, as omega-6s had already been shown to work. So the control group took omega-6s. Once again there was no strict avoidance of animal fats; rather the patients were ‘given dietary advice to encourage a low intake of animal fat and a plentiful intake of omega-6 fatty acids’. So we have no record of how much animal fat patients in each group had, and the untreated group were actually receiving treatment with omega-6 fatty acids, which had previously been shown to work in MS. So were the group treated with the omega-3 fatty acids.
Not surprisingly the investigators failed to find a statistically significant difference. If omega-3s were better, you would expect both groups to get better, but the omega-3 group to be ahead. This is what they found: The omega-3 group did better; 79 patients were unchanged or better and 66 were worse at two years. Of the omega-6 group, 65 were the same or better, and 82 were worse. The p value for this difference was 0.07, not quite making the usual 0.05 accepted significance level. Although the researchers were ethically right in not asking the control group patients to miss out on the benefits of dietary changes, this decision almost certainly cost them the chance to get a p value which would be regarded as ‘proof’ by doctors in general.
The first RCT of diet in MS mentioned in the Dietary Fats in MS section found a statistically significant improvement in the group which took fish oil, with a reduction in relapse rate of 0.8 relapses per year.10 A Dutch review in 2005 concluded that fish oil may be beneficial in MS both through its immune mechanism of action and through structural effects within the CNS.11
Overview
Essential fatty acids form an important part of the whole healing package with MS. Omega 3s should be more helpful than omega 6s based on the literature. Major authorities in MS are now recommending this be brought to the attention of people with MS.
- Millar JH, Zilkha KJ, Langman MJ, et al. Double-blind trial of linoleate supplementation of the diet in multiple sclerosis. Br Med J 1973; 1:765-768
- Paty DW, Cousin HK, Read S, et al. Linoleic acid in multiple sclerosis: failure to show any therapeutic benefit. Acta Neurol Scand 1978; 58:53-58
- Bates D, Fawcett PR, Shaw DA, et al. Polyunsaturated fatty acids in treatment of acute remitting multiple sclerosis. Br Med J 1978; 2:1390-1391
- Meade CJ, Mertin J, Sheena J, et al. Reduction by linoleic acid of the severity of experimental allergic encephalomyelitis in the guinea pig. J Neurol Sci 1978; 35:291-308.
- Dworkin RH, Bates D, Millar JH, et al. Linoleic acid and multiple sclerosis: a reanalysis of three double-blind trials. Neurology 1984; 34:1441-1445.
- Excellence. NIfC. Multiple sclerosis. Management of multiple sclerosis in primary and secondary care. London: National Institute for Clinical Excellence, 2003
- Fitzgerald G, Harbige LS, Forti A, et al. The effect of nutritional counselling on diet and plasma EFA status in multiple sclerosis patients over 3 years. Hum Nutr Appl Nutr 1987; 41:297-310
- Graham J. Multiple sclerosis: a self-help guide to its management. Northamptonshire: Thorsons, 1987
- Bates D, Cartlidge NE, French JM, et al. A double-blind controlled trial of long chain n-3 polyunsaturated fatty acids in the treatment of multiple sclerosis. J Neurol Neurosurg Psychiatry 1989; 52:18-22.
- Weinstock-Guttman B, Baier M, Park Y, et al. Low fat dietary intervention with omega-3 fatty acid supplementation in multiple sclerosis patients. Prostaglandins Leukot Essent Fatty Acids 2005
- van Meeteren ME, Teunissen CE, Dijkstra CD, et al. Antioxidants and polyunsaturated fatty acids in multiple sclerosis. Eur J Clin Nutr 2005; 59:1347-1361
- Millar JH, Zilkha KJ, Langman MJ, et al. Double-blind trial of linoleate supplementation of the diet in multiple sclerosis. Br Med J 1973; 1:765-768
- Paty DW, Cousin HK, Read S, et al. Linoleic acid in multiple sclerosis: failure to show any therapeutic benefit. Acta Neurol Scand 1978; 58:53-58
- Bates D, Fawcett PR, Shaw DA, et al. Polyunsaturated fatty acids in treatment of acute remitting multiple sclerosis. Br Med J 1978; 2:1390-1391
- Meade CJ, Mertin J, Sheena J, et al. Reduction by linoleic acid of the severity of experimental allergic encephalomyelitis in the guinea pig. J Neurol Sci 1978; 35:291-308.
- Dworkin RH, Bates D, Millar JH, et al. Linoleic acid and multiple sclerosis: a reanalysis of three double-blind trials. Neurology 1984; 34:1441-1445.
- Excellence. NIfC. Multiple sclerosis. Management of multiple sclerosis in primary and secondary care. London: National Institute for Clinical Excellence, 2003
- Fitzgerald G, Harbige LS, Forti A, et al. The effect of nutritional counselling on diet and plasma EFA status in multiple sclerosis patients over 3 years. Hum Nutr Appl Nutr 1987; 41:297-310
- Graham J. Multiple sclerosis: a self-help guide to its management. Northamptonshire: Thorsons, 1987
- Bates D, Cartlidge NE, French JM, et al. A double-blind controlled trial of long chain n-3 polyunsaturated fatty acids in the treatment of multiple sclerosis. J Neurol Neurosurg Psychiatry 1989; 52:18-22.
- Weinstock-Guttman B, Baier M, Park Y, et al. Low fat dietary intervention with omega-3 fatty acid supplementation in multiple sclerosis patients. Prostaglandins Leukot Essent Fatty Acids 2005
- van Meeteren ME, Teunissen CE, Dijkstra CD, et al. Antioxidants and polyunsaturated fatty acids in multiple sclerosis. Eur J Clin Nutr 2005; 59:1347-1361