Original Article
Epidemiological
Cigarette Smoking, Alcohol Consumption and Overweight in Multiple Sclerosis: Disability Progression

https://doi.org/10.1016/j.arcmed.2017.03.002Get rights and content

Background

The rate at which disability progresses in multiple sclerosis (MS), and its severity, have been associated with modifiable lifestyle habits.

Objective

To investigate the risk of disability progression in MS patients according to tobacco and alcohol consumption and to the presence of overweight.

Methods

This was a follow-up of MS cases from a concluded case-control study (National Institute of Neurology and Neurosurgery, Mexico 2010–2013). The evolution in EDSS (Expanded Disability Scale Score) units was followed through a medical record review. Kaplan Meier statistics and multivariate Cox regression analysis were performed.

Results

Of 181 cases, 63.5% were women and 82.5% had relapsing remitting MS. Study duration was 19.95 ± 15.24 months. The disease progressed faster in daily smokers than in non-smokers (p = 0.0168). In overweight patients, disability progressed faster than in normal weight patients (p = 0.0249). Ex-consumers of alcohol had lower risk of progression than current consumers (HR = 0.33 CI 95% = 0.14–0.83, p = 0.019) and both daily and ex-smokers presented higher risk of progression than non-smokers (HR = 2.32 CI 95% = 1.14–4.72, p = 0.020 and HR = 3.56, CI 95% = 1.21–10.46, p = 0.021). Stratifying by gender, the effects of smoking and overweight were only found in men.

Conclusions

Smoking is associated with rapid disability progression in MS. Our results suggest that cessation of tobacco and alcohol consumption could be clinically beneficial. Although there is association between overweight and disability progression in men, a further exploration of gender differences is necessary to corroborate this finding.

Introduction

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS). It is characterized by an inflammatory and demyelinating process, occurs predominantly in women and symptoms appear at an average age of 30 years old (1). Clinical progression and axonal damage level vary between individuals and the causes that lead to evolution from non-progressive to progressive forms are not fully known (2).

MS etiology has been linked to complex genetic susceptibility profiles accompanied by environmental conditions (3). Several risk factors for MS associated with disability progression are currently in debate: ethnicity, education, age at disease onset, early treatment, obesity during early life, diet, cognitive impairment at diagnosis, brain atrophy and comorbidity are some of the sociodemographic and clinical factors with conflicting results 4, 5, 6, 7, 8, 9. On the other hand, well known risk factors as tobacco consumption are yet to be comprehended in the full extent of its impact on the progression of the disease (10).

Adverse health habits such as cigarette smoking, alcohol consumption, as well as reduced physical activity, have been reported frequently in MS patients (11); this implies a risk of developing other chronic diseases and theoretically all disease's outcomes can be affected by comorbidity (12). In a cohort study of 895 patients with MS, cigarette smoking was associated with severe and rapid progression of the disease (13).

Studies that addressed alcohol consumption and disability in MS show inconclusive results. Although alcohol consumption is not necessarily more frequent in MS patients (14), an association with mood disorders has been reported, making these patients particularly vulnerable to other complications (15). In contrast, other studies suggest that alcohol may have a protective effect on MS progression (as in other autoimmune diseases) (16).

Some studies report that young people with a background of obesity have increased risk of developing MS; although the pathophysiologic mechanism for this is not known, an association with vitamin D deficiency (common in overweight patients) has been proposed 17, 18, 19. Obesity in MS generates a state of cellular inflammation (20), in this context, recent studies elaborate the possible participation of the adipocyte which releases leptin and other adipokines. Leptin act a modulator of immune responses and induces a low grade inflammatory state (21) which could represent a risk for disease activity and long term progression (22).

Data on the distribution of MS in Latin America are limited, the prevalence rates estimated for Mexico range from 1.5–3 per 100 000 but there are reports of higher prevalence and of elevation of incidence up to ten times in some regions, explained by new and better protocols of diagnosis implemented in the country and to disease literacy 23, 24, 25, 26, 27. A recent descriptive study exposes clinical and demographic characteristics or 313 Mexican patients with MS with similar results to those reported in literature (28). To our knowledge, there is not background of follow up studies of Mexican patients with MS that explore disability and health behaviors trough time.

The aim of this study was to investigate the risk of disability progression in MS patients related to cigarette smoking, alcohol consumption and to the presence of overweight.

Section snippets

Study Design and Ethic Approval

This follow-up study is a secondary analysis derived from the case-control study Risk factors associated with multiple sclerosis in Mexico: A multicenter study conducted from 2010–2013 and approved by the Ethics, Biosafety and Research Committees of the National Institute of Neurology and Neurosurgery (INNN) and of the National Institute of Public Health (INSP) (approval number CI.790, No.684). With the authorization from the institutional authorities and committees, cases were followed through

Exploratory Phase

The patient population consisted of 181 diagnosed MS cases that met the inclusion criteria, 36.46% were men and 66.54% women. The average age at baseline was 34.02 ± 9.79 years. Regarding MS type, 82.87% were relapsing remitting (RRMS), 6.25% primary progressive (PPMS), 9.36% secondary progressive (SPMS) and only 1.10% were progressive relapsing (PRMS). The average time between onset of symptoms and diagnosis of MS was 6.15 ± 5.71 years. Sociodemographic and clinical characteristics at baseline

Discussion

In this study, differential risk of disability progression by gender in smokers and overweight MS patients was found.

Lower risk of disability progression was present in alcohol non-consumers but this was not consistent when stratifying the analysis. Some investigations reported that wine and beer drinking may have a protective effect in MS (9). We didn't address the type of beverage in this study.

Various authors have reported associations between tobacco consumption and disability progression

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