Original ArticleEpidemiologicalCigarette Smoking, Alcohol Consumption and Overweight in Multiple Sclerosis: Disability Progression
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
References (43)
- et al.
Multiple sclerosis
Lancet Lond Engl
(2008) - et al.
Prognostic factors associated with long-term disability and secondary progression in patients with Multiple Sclerosis
Mult Scler Relat Disord
(2016) - et al.
Obesity during childhood and adolescence increases susceptibility to multiple sclerosis after accounting for established genetic and environmental risk factors
Obes Res Clin Pract
(2014) - et al.
Vitamin D status and age of onset of demyelinating disease
Mult Scler Relat Disord
(2014) - et al.
The changing demographic pattern of multiple sclerosis epidemiology
Lancet Neurol
(2010) - et al.
The worldwide prevalence of multiple sclerosis
Clin Neurol Neurosurg
(2002) - et al.
Smoking worsens multiple sclerosis prognosis: two different pathways are involved
J Neuroimmunol
(2015) - et al.
Low serum uric acid levels in patients with multiple sclerosis and neuromyelitis optica: An updated meta-analysis
Mult Scler Relat Disord
(2016) - et al.
Defining the clinical course of multiple sclerosis: Results of an international survey. National Multiple Sclerosis Society (USA) Advisory Committee on Clinical Trials of New Agents in Multiple Sclerosis
Neurology
(1996) Aetiology of multiple sclerosis
QJM Mon J Assoc Physicians
(2011)
Short-term MRI measurements as predictors of EDSS progression in relapsing-remitting multiple sclerosis: grey matter atrophy but not lesions are predictive in a real-life setting
PeerJ
Cognitive impairment at diagnosis predicts 10-year multiple sclerosis progression
Mult Scler Houndmills Basingstoke Engl
Importance of early treatment initiation in the clinical course of multiple sclerosis
Mult Scler
Associations of Lifestyle, Medication, and Socio-Demographic Factors with Disability in People with Multiple Sclerosis: An International Cross-Sectional Study
PloS One
Self-reported levels of education and disability progression in multiple sclerosis
Acta Neurol Scand
Smoking and multiple sclerosis: an updated meta-analysis
PloS One
High frequency of adverse health behaviors in multiple sclerosis
Mult Scler Houndmills Basingstoke Engl
Modifiable environmental factors in multiple sclerosis
Arq Neuropsiquiatr
Tobacco smoking and disability progression in multiple sclerosis: United Kingdom cohort study
Brain J Neurol
Patients with multiple sclerosis do not necessarily consume more alcohol or tobacco than the general population
Arq Neuropsiquiatr
Adverse health behaviours are associated with depression and anxiety in multiple sclerosis: A prospective multisite study
Mult Scler
Cited by (26)
Impact of tobacco smoking on disease-specific outcomes in common neurological disorders: A scoping review
2024, Journal of Clinical NeuroscienceThe effects of different types of smoking on recovery from attack in hospitalized multiple sclerosis patients
2023, Clinical Neurology and NeurosurgeryThe effect of the Australian bushfires and the COVID-19 pandemic on health behaviours in people with multiple sclerosis
2021, Multiple Sclerosis and Related DisordersCitation Excerpt :The importance of positive health behaviours such as exercise on neurorehabilitation and managing MS symptoms is well known (Dalgas et al., 2019, Vollmer et al., 2012). Adverse health behaviours and factors such as physical inactivity, excessive alcohol consumption, overweight, and smoking are common, and associated with worse health outcomes in people with MS (Marrie et al., 2009, Beier et al., 2014, Paz-Ballesteros et al., 2017). Further, smoking and obesity are linked to increased risk for severe COVID-19 infection in the general population (Gupta et al., 2021), while prehabilitation (e.g. exercise, nutrition, smoking cessation, and stress reduction) may improve the immune system response to future stressors such as infection (Silver, 2020).
Oxygen Cost During Mobility Tasks and Its Relationship to Fatigue in Progressive Multiple Sclerosis
2019, Archives of Physical Medicine and RehabilitationCitation Excerpt :Although there was substantial variability, on average, the participants with MS used 2.81 times more energy for mobility tasks compared to matched controls (fig 2). Since the number of people who smoked was greater in the MS group (n=5) and smoking could affect oxygen cost measurements,42-44 we examined the effect of smoking. Smoking status was not significantly different between participants with MS and controls (P=.123) (see table 1).
Body Mass Index in Multiple Sclerosis modulates ceramide-induced DNA methylation and disease course
2019, EBioMedicineCitation Excerpt :Epidemiological studies have carefully assessed the BMI as risk factor for MS [12,13,16–20] and many studies have supported the concept of long-term effects of the BMI on the disease, as obesity or high body mass in childhood or adolescence will induce disease onset many years later [12,13,19,20]. Finally, recent studies have highlighted a relationship between BMI and disease severity [21–25] and to some extent, progression [26,27], thereby further supporting the need to investigate the molecular mechanisms responsible for these long-term effects. Increased lipid synthesis in multiple tissues, including adipose tissue, liver, skeletal muscle and plasma has been associated with high BMI [28–31].
The associated risk factors for underweight and overweight high school students in Cambodia
2018, Diabetes and Metabolic Syndrome: Clinical Research and ReviewsCitation Excerpt :Some studies indicated that the increasing underweight/overweight outbreak is associated with societal, demographic and cultural settings involving both dietary behaviors and physical activity levels [18–24]. Pengpid, S. et al. and Paz-Ballesteros, W. C., et al. showed that the smoking cigarettes and alcohol use were strongly associated with overweight among adults [18,25]. Although our study did not show a significant relationship between smoking cigarettes and abnormal weights (underweight and overweight), alcohol use was strongly significantly related to underweight.