Q.  What is wellness?

A.  Management of multiple sclerosis (MS) has traditionally focused on disease modifying therapies (DMTs) and treatment of chronic symptoms. There is now a growing interest in wellness practices that incorporate a comprehensive approach to health and well-being. These practices augment rather than replace traditional MS management.

Abiding by a healthy diet, exercising routinely, maintaining sufficient vitamin D levels, abstaining from tobacco use, incorporating stress management techniques, remaining active in the community, and engaging in health maintenance are all ways in which persons living with MS can help improve the way they live their everyday lives.

Q.  What diet is best for MS patients?

A.  We recommend a Mediterranean-style diet as outlined in the 2015-2020 Dietary Guidelines for Americans. The Mediterranean diet limits sugar and processed foods, limits sodium intake, and emphasizes fruits, vegetables, whole grains, and lean proteins such as fish. This diet is recommended for the general population and may have added benefits for people with MS by helping to prevent vascular risk factors that have been linked with worse long-term outcomes. In addition to the Mediterranean diet, other diets have been proposed for MS, some of which are currently being tested in clinical trials.

Q.  What should people with MS do for exercise?

A.  Exercise is safe in people with MS and is important for everyone to maintain fitness and overall health. In addition, many clinical trials suggest that exercise can lead to small but clinically important improvements in fatigue, depression, walking, balance, and overall quality of life. We recommend that all adults age 18-64 with mild to moderate disability get at least 30 minutes of moderate intensity aerobic activity twice a week and do strength training exercises for major muscle groups twice a week, consistent with Canadian Physical Activity Guidelines. At the Mellen center we counsel adult 65 and older to continue to exercise under the supervision of their primary physician.

The appropriate intensity of exercise can be difficult for people with MS to judge. Exercise should not be painful, and we do not recommend overexertion. As a general rule, if a person feels fatigued for more than 2 hours after completing an exercise session, they should decrease the amount or intensity of the physical activity. In addition, all MS patients should take rest breaks when exercising, 30-120 seconds at a time, and stay cool, using cooling equipment if necessary.

Q.  Why is vitamin D supplementation important?

A.  We recommend vitamin D supplementation to maintain 25-hydroxy vitamin D levels between 40 and 70 ng/mL. Levels below 30 ng/mL are associated with osteoporosis and an increased risk of fractures. In addition, in several key observational studies, lower vitamin D levels were associated with increased disease activity and worsening disability. Refer to the Mellen Center Approach on Multiple Sclerosis and Vitamin D for more details.

Q.  Why should MS patients abstain from tobacco use?

A.  In addition to its other harmful side effects, tobacco smoking is associated with worsening disability and increased mortality in people with MS. Long-term outcomes are better for people who quit smoking compared to active smokers. We recommend that all MS patients who smoke be encouraged and assisted to quit.

Q.  What is the best strategy to help people stop smoking?

A.  Optimal strategies in smoking cessation use both behavioral and pharmacologic interventions. Behavioral interventions include written materials containing advice on quitting, multisession group therapy programs, and individual counseling. Pharmacologic therapies include nicotine replacement therapy, varenicline, bupropion, cytisine, and nortriptyline. Combination therapies, such as varenicline with nicotine replacement, may be more effective than either treatment alone.

Q.  Is there a role for stress management in MS?

A.  Several randomized controlled trials suggest a potential role for stress management programs in MS. Most trials were focused on improving depression, fatigue, or quality of life, but one trial also demonstrated a reduction in MRI markers of disease activity. Unfortunately, these effects did not carry over into the post-treatment follow-up period. Nevertheless, techniques such as mindfulness training can be offered to interested patients.

Q.  Is social engagement important for people with MS?

A.  Multiple studies suggest an association between social engagement and lower risk of all-cause mortality. In addition, social engagement has been associated with a lower risk of cognitive decline and higher cognitive performance in people with dementia. Although the reason for this association is not clear, social engagement may have benefits for other chronic neurodegenerative disorders such as MS.

Q.  What comorbidities have been studied in MS?

A.  In line with a holistic approach to health and well-being, there is a growing interest in the impact of comorbidities on disease-related outcomes in MS. Comorbidity refers to a coexisting disease state other than the condition of interest and is distinct from complications of the pre-specified disease. Most studies have focused on obesity, vascular comorbidities, and psychiatric disorders in MS.

Q.  What is the prevalence of obesity in MS?

A.  Estimates of the prevalence of obesity in the MS population have varied widely. In the largest survey, which included 8,983 responders, a quarter of participants were obese and close to one-third were overweight. This may be an underestimate of the true prevalence of overweight and obesity, as respondents tend to under-report their true weight in self-reported evaluations.

Q.  What is the impact of obesity on disease activity and worsening disability in MS?

A.  Overall, there is insufficient evidence to support a clear relationship between weight status and disease activity or worsening disability in MS. Results from observational studies have shown conflicting results, and there have been no clinical trials to date. However, maintaining a healthy weight has other important benefits and is part of overall health and wellness.

Q.  What is the prevalence of vascular risk factors and vascular comorbidities in MS?

A.  Estimates of the prevalence of vascular risk factors and vascular comorbidities have varied widely, as have the quality of studies used to make these estimates. In a recent systematic review, the prevalence range for common vascular risk factors and comorbidities was provided for included studies: 6.75% to 8.57% for diabetes type II, 3.0% to 47.8% for hyperlipidemia, 0% to 47.8% for hypertension, 0.78% to 22.2% for coronary artery disease, 1.2% to 1.4% for ischemic stroke, and 1% to 4% for peripheral vascular disease.

Q.  Are certain vascular risk factors or vascular comorbidities more common in MS populations compared to the general public?

A.  Ischemic heart disease appears to be more common in MS populations compared to the general public, but the data for other vascular risk factors and comorbidities is inconsistent.

Q.  What is the impact of vascular risk factors and vascular comorbidities on MS disease activity and worsening of disability?

A.  Some studies have suggested an association between vascular risk factors and MRI lesion burden in MS. There is also some evidence that vascular risk factors and vascular comorbidities are associated with faster progression of disability. The presence of multiple vascular risk factors may increase the risk of disability more than any one risk factor alone.

Q.  What is the prevalence of psychiatric disorders in MS?

A.  Reports on the prevalence of depression, bipolar disorder (BPD), and anxiety disorders in the MS population have varied widely. In a recent systematic review, reports of the prevalence of psychiatric disorders ranged from 4.98% to 58.9% for depression, 0% to 16.2% for BPD, and 1.2% to 44.6% for anxiety disorders. All studies of depression and BPD that included a comparator population found a higher prevalence of mood disorders in the MS population.

Q.  What is the impact of psychiatric disorders on quality of life in MS?

A.  Depression, BPD, and anxiety disorders have a major impact on quality of life in MS. Depression, which has been studied the most, can affect multiple functional domains including energy, cognition, perception of health, and sexual function. Moreover, patients with MS who have depression may have worse long-term disease-related outcomes as a result of decreased adherence to DMTs.

Q.  What is the risk of suicide in MS?

A.  In a 2012 systematic review investigating the association between MS and suicidal behavior, the majority of included studies found rates of completed suicide 1.6- to 14-times higher than the general public. However, a recent study conducted in France found no difference in suicide-associated mortality rates in an MS cohort compared with population norms, suggesting that suicide risk in MS has decreased in recent years.

Q.  How should MS providers address depression in clinical practice?

A.  Depression is often under-recognized and undertreated in MS. We recommend regular depression screening in clinical practice. Many screening tests have been validated. At the mellen center we use the Patient Health Questionnaire-9 at each clinical visit. Management of psychiatric disorders should follow general practice guidelines.

Q.  Why do MS patients need a primary care doctor?

A.  In addition to treatment and regular monitoring from a neurologist with MS experience, MS patients need a primary care doctor to help with age-appropriate health screening, up to date immunization, and management of medical comorbidities. As mentioned previously, some of these comorbidities are of particular importance for people with MS. At the Mellen Center we encourage our patients to see a primary physician if they do not already have one.

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