British Journal of Nutrition (2007), 98, Suppl. 1, S46–S53
q The Authors 2007
Polyunsaturated fatty acids in the pathogenesis and treatment ofmultiple sclerosis
Laurence S. Harbige1,2* and Mohammad K. Sharief 31Centre for Bioscience Research, School of Science, University of Greenwich at Medway, United Kingdom2Medway School of Pharmacy,University of Kent and University of Greenwich, United Kingdom3Department of Neurology, King's, Guy's and St Thomas' Hospital, London, United Kingdom
Epidemiological, biochemical, animal model and clinical trial data described in this overview strongly suggest that polyunsaturated fatty acids,particularly n-6 fatty acids, have a role in the pathogenesis and treatment of multiple sclerosis (MS). Data presented provides further evidencefor a disturbance in n-6 fatty acid metabolism in MS. Disturbance of n-6 fatty acid metabolism and dysregulation of cytokines are shown tobe linked and a "proof of concept clinical trial" further supports such a hypothesis. In a randomised double-blind, placebo controlled trial of ahigh dose and low dose selected GLA (18 : 3n-6)-rich oil and placebo control, the high dose had a marked clinical effect in relapsing-remittingMS, significantly decreasing the relapse rate and the progression of disease. Laboratory findings paralleled clinical changes in the placebogroup in that production of mononuclear cell pro-inflammatory cytokines (TNF-a, IL-1b) was increased and anti-inflammatory TGF-b markedlydecreased with loss of membrane n-6 fatty acids linoleic (18 : 2n-6) and arachidonic acids (20 : 4n-6). In contrast there were no such changes in thehigh dose group. The improvement in disability (Expanded Disability Status Scale) in the high dose suggests there maybe a beneficial effect on
neuronal lipids and neural function in MS. Thus disturbed n-6 fatty acid metabolism in MS gives rise to loss of membrane long chain n-6 fattyacids and loss of the anti-inflammatory regulatory cytokine TGF-b, particularly during the relapse phase, as well as loss of these important neural
fatty acids for CNS structure and function and consequent long term neurological deficit in MS.
Multiple sclerosis: Linoleic acid: Gamma-linolenic acid: Arachidonic acid: Clinical trials: Cytokines
Background to multiple sclerosis and its pathogenesis
by pro-inflammatory cytokines such as tumour necrosisfactor-a (TNF-a), interleukin-1b (IL-1b) and interferon-g
Multiple sclerosis (MS) is a CNS-specific demyelinating dis-
(IFN-g)15. Furthermore studies have shown that these cyto-
ease, and is the most common neurological disorder that
kines exert direct myelinotoxic properties16,17 and prolong
occurs in young adults1,2. The majority of patients with MS
the disease process in experimental autoimmune encephalo-
have the relapsing-remitting form of the disease, characterised
myelitis (EAE), an animal model of MS18,19,20. TNF-a,
by attacks (relapses) interspersed with periods of recovery
IL-1b and IFN-g have all been shown to be present in
(remission). The disease is most prevalent (30 – 100 þ cases
CNS active lesions in MS and elevated amounts of these
per 100 000 people) in Western Europe, Southern Canada,
cytokines are secreted from MS peripheral blood mono-
Northern United States, Southern Australia and New Zealand
nuclear cells (PBMC)21 – 25. Many studies, including our
and of low frequency (0 – 19 per 100,000) in Asia, Central
own, have also shown that an increase in these inflammatory
America, Africa and Greenland (See Fig. 1). Between 2 and
cytokines coincides with the relapse phase of the dis-
3 million people Worldwide are thought to live with MS.
ease25 – 33. Furthermore some studies have shown that
Although the aetiology of MS remains unknown there is
transforming growth factor-beta1 (TGF-b1), a potent anti-
strong evidence for the presence of autoimmune mechanisms
inflammatory and immunosuppressive cytokine, is reduced
in the disease pathogenesis3,4. Studies have shown that
during the relapse phase and increases as the patient
MS patients have a much higher number of neuroantigen
enters remission25,34,35. In addition we have demonstrated
e.g. myelin basic protein (MBP) and myelin oligodendrocyte
that the balance between biologically active TGF-b1 and
glycoprotein (MOG) autoreactive T-cells, which are in an
the pro-inflammatory TNF-a, IL-1b and IFN-g is dysregu-
increased state of activation compared with healthy controls,
lated during MS relapse-remission25. The actual processes
and which increase during exacerbation4 – 13.
of axonal damage e.g. chronic inflammation, demyelination
Cytokines from activated T cells and macrophages have
and astrogliosis in MS is complex but white matter inflam-
been strongly implicated in the pathogenesis of MS14. For
mation and demyelination are considered to determine dis-
example, the up-regulation of adhesion molecules on endo-
ease severity, whilst recent studies suggest that axonal
thelial cells and the subsequent infiltration of activated T
damage in MS begins in the early stages of the disease
cells into the CNS are immunopathogenic events controlled
and contributes to disability36,37. Furthermore some have
* Corresponding author: Dr Laurence Harbige, fax 0044 (0)1813319805, email L.Harbige@gre.ac.uk
Polyunsaturated fatty acids and multiple sclerosis
reduced in the plasma, platelets, erythrocytes, leucocytes andcerebrospinal fluid with changes in the unsaturated fatty acidcomposition of brain white matter in MS patients, much ofthis early work being undertaken at the National Hospital,Queen Square in London49 – 60. But there are also inconsistentreports61 – 64and Love et al.65 observed that reduced linoleicacid was not specific to MS and occurred in patients withacute non-neurological illness. However many of these differ-ences between studies are perhaps not surprising given cul-tural and ethnic differences, dietary variability (particularlywhen someone is ill), possible desaturase gene polymorphism,disease variability, serum verses cellular fatty acids and meth-odological differences for example total lipid fatty acidsverses phospholipids fatty acid analysis.
Previously we proposed nervonic acid as a marker of CNS
myelin damage in MS66 and found that MS patients consum-ing a diet rich in polyunsaturated fatty acids particularly lino-
Fig. 1. Geographical distribution of multiple sclerosis (from Adams C (1989)
leic acid had an inverse relationship between erythrocyte
colour atlas of multiple sclerosis and other myelin disorders, wolfe medicalpublications ltd, with permission).
membrane linoleic acid and nervonic acid (24 : 1)67. A similarfinding was described by Homa et al.68, showing a decrease inerythrocyte lignoceric acid (24 : 0) in sunflower oil (rich in
considered metabolic disturbances in some MS patients to
linoleic acid) supplemented MS patients. In an open, uncon-
be behind primary oligodendrocyte damage with secondary
trolled 2 year fish oil intervention study by Nordvik et al.69
in MS, they observed significant reductions in plasma totalphospholipid nervonic and lignoceric acids with time and
Nutritional epidemiology of multiple sclerosis
clinical improvement. Taken together the above indicate thatnervonic and lignoceric acids could be useful pathogenic bio-
Over half a century ago Roy Swank40 found a positive
markers of myelin damage and/or biomarkers for monitoring
relationship between fat intake as well as annual milk pro-
fatty acid treatments. We also found that the atypical erythro-
duction and MS in Scandinavian countries. Furthermore
cyte electrophoretic response of MS patients was positively
studies by Alter et al.41 implicated animal fat rich in satu-
correlated with membrane linoleic acid and could be corrected
rated fatty acids as a causal factor in MS and Wolfgram42
by a diet rich in polyunsaturated fatty acids particularly lino-
in an analysis of World Health Organisation (WHO) annual
leic acid67. This is in agreement with Field and Joyce71 who
mortality statistics found a similar geographical distribution
found an increase in erythrocyte electrophoretic response in
between MS coronary heart disease and cancer of the
MS patients supplemented with evening primrose oil (EPO).
colon. In the multivariate analysis (inclusive of socioeco-
However, Field et al.71, Field and Joyce70 interpreted their
nomic and medical services) of 20 countries Arganoff and
electrophoretic results, without an analysis of membrane
Goldberg43 not only implicated meat and dairy fats in posi-
fatty acids, as an effect of the gamma-linolenic (GLA,
tive correlations with MS, as noted previously, but also veg-
18 : 3n-6) component of the oil. EPO contains about 70 % lino-
etable, seed, nut and fish, foods rich in both the n-6 and n-3
leic acid and 8 – 10 % GLA, therefore it is more likely that the
polyunsaturated fatty acids, in negative correlations with MS.
effect observed by Field et al was due to the linoleic acid com-
Several other studies also confirmed strong MS associations
ponent of the oil rather than the GLA.
with dairy and other animal fats44 – 46. Similar observations
We have also investigated the metabolic relationships
have also been made more recently by Esparsa et al.47 in a
between the n-6 fatty acids in both healthy controls and MS
large study (36 countries) assessing the impact of diet on
PBMC total phospholipids (Figs. 2, 3 and 4). Both controls
MS mortality. They found that the higher the saturated
and MS patients (remission phase) demonstrate a positive cor-
fatty acid intake the higher the MS mortality and the higher
relation between linoleic acid (18 : 2n-6) and arachidonic acid
the polyunsaturated to saturated fatty acid ratio the lower
(20 : 4n-6) as expected, although these n-6 fatty acids were
the MS mortality. However the large single country study,
low in a proportion of the MS patients studied (Fig. 2). More-
the Nurses' Health Study in the USA failed to show any
over, the relationship between linoleic acid (18 : 2n-6) and
relationship between MS and fat intake in women48. Thus
dihomo-g-linolenic acid (DGLA), and also between DGLA
the majority of epidemiological studies indicate that foods
(20 : 3n-6) and arachidonic acid (20 : 4n-6) is clearly disturbed
rich in saturated fatty acids are detrimentally associated
in MS compared with healthy controls (Figs. 3 and 4). This
with MS, whilst polyunsaturated fatty acid rich foods are ben-
may indicate a problem with D6 and D5 desaturation and /
eficially associated with MS.
or a greater requirement for these n-6 fatty acids in manyof the MS patients studied, about 20 – 30 percent of thepatients showed lower than normal PBMC phospholipid
Biochemical and metabolic studies of fatty acids in
DGLA and arachidonic acid. In agreement with our findings
Homa et al.55 has also reported a similar disturbance in the
There is much evidence that the n-6 fatty acids particularly
relationship between linoleic acid and arachidonic acid in MS
linoleic (18 : 2n-6) and arachidonic acids (20 : 4n-6) are
erythrocyte membrane lipids compared to healthy controls.
L. S. Harbige and M. K. Sharief
Fig. 3. Relationship between linoleic acid (18 : 2n-6) and dihomo-g-linolenicacid (20 : 3n-6) in peripheral blood mononuclear cell total phospholipids of
healthy controls and multiple sclerosis.
Fig. 2. Relationship between linoleic acid (18 : 2n-6) and arachidonic acid(20 : 4n-6) in peripheral blood mononuclear cell total phospholipids of healthycontrols and multiple sclerosis.
Fatty acids and animal models of multiple sclerosis
Experimental autoimmune encephalomyelitis (EAE) is an
Furthermore when we compared MS and healthy control
experimentally induced CD4þT cell mediated autoimmune-
PBMC total phospholipid 20 : 2n-6 we found a significant 2
inflammatory and deyelinating disease in rodents often used
fold higher 20 : 2n-6 in MS patients in remission compared
as an animal model of MS. Studies in guinea pig and rat
to healthy controls and a significant 4 fold higher 20 : 2n-6
EAE treated with linoleic acid alone or a high linoleic and
in the relapse phase of the disease. It appears that in MS
low g-linolenic (GLA) acid rich oil (ratio 7 : 1) respectively,
there is a very active elongation of 18 : 2n-6 to 20 : 2n-6 in
have shown partial suppression of the incidence and severity
PBMCs and that this is even higher in the relapse phase
of EAE73,74. In a series of experiments we demonstrated
(accounting for the low 18 : 2n-6) indicating a disturbance in
important disease modifying effects of linoleic acid-rich oil
the normal metabolism or a higher requirement for DGLA
(containing no GLA) and GLA-rich oil on clinical and histo-
and arachidonic acid (20 : 2n-6 maybe further D8 desaturated
pathological manifestations of EAE. Depending on dose GLA
to DGLA?) by these n-6 fatty acid (20 : 4n-6) rich cells72, or
was completely protective in EAE, whereas linoleic acid had
both. This may also be reflective of the demand of cells and
a dose dependent action on the clinical severity of EAE,
myelin in the brain which are also n-6 fatty acid-rich
although not abolishing it75,76. Natural recovery in EAE is
(20 : 4n-6 and 22 : 4n-6), significantly Stanley Rapoport of
mediated by expansion of suppressor lymphoid cells77 some
the NIH has shown that the human brain requires 4 times
of which have been characterised as TGF-b producing
the amount of arachidonic acid (20 : 4n-6) than docosahexae-
CD4þT cells by Karpus and Swanborg78. Furthermore admin-
noic acid (22 : 6n-3) on a daily bases (ISSFAL 2006). In
istration of TGF-b protects in acute and relapsing EAE79,80
relation to 20 : 2n-6, although not discussed by the authors,
and prostaglandin inhibitors such as indomethacin augment
the Nordvik et al.69 study demonstrated a reduction with
EAE81. In-addition during the natural recovery phase from
time of 20 : 2n-6 running parallel with clinical improvement,
EAE TGF-b secreting T cells can inhibit EAE effector cells
a similar finding to the nervonic and lignoceric acids men-
and TGF-b is expressed in the CNS78,82,83. Consistent with
tioned earlier. Therefore 20 : 2n-6 may also be a useful
these findings the protective effect of GLA-rich oil in EAE is
marker of disease progression and/or monitoring fatty acid
linked to increased T cell TGF-b transcription and increased
treatments in MS.
production of PGE 76
Polyunsaturated fatty acids and multiple sclerosis
reductions in the relapse rate and disability progression asmeasured by the Expanded Disability Status Scale (EDSS)69which quantifies disability in MS in eight functional systems(pyramidal, cerebellar, brainstem, sensory, bowel and bladder,visual, cerebral, other). It also appears based on open studiesby us and by Roy Swank that long term low saturated fatdiets containing both n-6 and n-3 fatty acids improve thecourse of the disease89 – 93.
Based on our MS fatty acid metabolic data and experimen-
tal animal model work, described above, we undertook a ran-domised double-blind placebo controlled trial to determine theeffects of supplementation with a selected GLA (18 : 3n-6)-rich borage oil. This oil, BGC20-884 was high in sn-2 GLA,low in monoenes and contained only natural levels of vitaminE. This study evaluated two doses of BGC20-884 (low dose -5 gram and high dose - 14 gram per day) and a placebo control(polyethylene glycol 400) on the clinical course and PBMCcytokine and membrane fatty acid profiles of 36 patientswith active MS over 18 months94. Patients were diagnosedand assessed using international criteria for MS. Relapserate and EDSS (Expanded Disability Status Scale) wereassessed every three months and blood taken and PBMCs iso-lated for cytokine studies and membrane fatty acids. Highdose
reduced the relapse rate (Fig. 5) and disability progression
as measured by EDSS (Fig. 6) compared with the placebo con-trol and low dose BGC20-884 treatment. In patients where we
had follow up samples available PBMC cytokine changeswere found to run parallel with the clinical findings e.g. theplacebo control group showed significant decreases in theTGF-b/TNF-a and TGF-b/IL-1b ratios and associated loss of
n-6 fatty acids particularly linoleic (18 : 2n-6) and arachidonic
Fig. 4. Relationship between dihomo-g-linolenic acid (20 : 3n-6) and arachido-
acid (20 : 4n-6) over time. Consistent with our findings
nic acid (20 : 4n-6) in peripheral blood mononuclear cell total phospholipids of
healthy controls and multiple sclerosis.
linoleic and arachidonic acids over time in MS erythrocytephospholipids. In contrast high dose BGC20-884 treatment
showed no changes in TGF-b/TNF-a and TGF-b/IL-1b
Clinical trials and intervention studies in multiple sclerosis
ratios and no changes in membrane n-6 fatty acids compared
with the placebo group. We also found positive correlationsbetween PBMC phospholipid arachidonic acid composition
Clinical trials to test the efficacy of linoleic acid-rich sun-
flower oil in MS patients by Miller et al.84 and Bates et al.85
and DGLA and TGF-b1 production (r ¼ 0·36, P , 0·001,
over 2 years showed a reduction in the relapse rate and sever-
n ¼ 74) ex vivo when all samples were included in the
ity of the disease relapse, but Paty et al.86 found no such
analysis. The EDSS improvement in the high dose group
effect. Nevertheless, Dworkin et al.87 in a statistical revalua-tion of the combined data of all three trials revealed signifi-cantly reduced relapse rate and severity, and in mildlyaffected a decrease in the long term progression of the disease.
The Millar et al.84 study based in two centres London and Bel-fast is particularly interesting as they observed that "the sever-ity of the relapses, differed markedly between the treated andthe control groups at both centres" relapses being twice assevere in the control group. Compared with current b-inter-feron treatment of MS the efficacy of linoleic acid-rich sun-flower oil in the Miller et al study is quite remarkable. Fishoil rich in long chain n-3 fatty acids has also been studiedin MS88, no significant differences between fish oil treatedand untreated MS patients was observed, there was, however,a trend for less deterioration in the fish oil treated group. In a 2
Fig. 5. Mean annualised relapse rate per patient for multiple sclerosis
year open intervention study MS patients given fish oil and
patients receiving high (n ¼ 11) and low dose (n ¼ 7) GLA-rich oil or placebo
advised to lower their saturated fat intake had significant
control (n ¼ 10) over 18 months.
L. S. Harbige and M. K. Sharief
as arachidonic acid are important in the growth and differen-tiation of oligodendrocytes and in myelination104 – 108 whichwould therefore be of importance in the stimulation, growthand recovery of these cells in MS. These findings provide alink between, dietary, metabolic, immunological and neuro-biological aspects of MS and therefore for the first time wecan begin to make sense of the wealth of apparently uncon-nected aspects of MS, particularly in relation to dietary fats.
More basic research is still required such as characterisationof possible desaturase gene polymorphisms, lymphocyte desa-turase gene expression and analysis of specific lymphocytephospholipid classes and their fatty acid composition in
Fig. 6. Disability progression as measured by the EDSS (Expanded DisabilityStatus Scale) in multiple sclerosis patients receiving high (n ¼ 11) and low
relation to cytokine and chemokine gene expression and pro-
dose (n ¼ 7) GLA-rich oil or placebo control (n ¼ 10) over 18 months.
duction. This should be undertaken in well defined MS patientgroups e.g. active MS and primary and secondary chronic pro-gressive forms of the disease and over an extended period of
also suggests there maybe a beneficial effect on neuronal
time. Furthermore large well controlled clinical trials with
lipids and neural function in MS. The study thus further sup-
different doses of well characterised and safe fatty acid formu-
ports our hypothesis of dysregulation of fatty acid metabolism
lations as well as manipulation of dietary saturated fatty acids
and cytokines in MS25,76.
could be undertaken. Clinical trials should include MRI, MR
To summarise and extend this section on clinical trials there
spectroscopy and analysis of lesion burden and cortical gray
is evidence to show a beneficial effect of n-6 and possibly n-3
matter density in order to investigate any possible effects of
fatty acids in MS. The mechanisms by which the n-3 or the
polyunsaturated fatty acids on myelination, neuronal, dentritic,
n-6 fatty acids influence the immune-inflammatory response
glial and neurite packing densities. In addition biochemical
in MS are however likely to be different72. Both the n-6 (ara-
monitoring of peripheral blood cell membrane phospholipid
chidonic acid) and n-3 (docosahexaenoic acid) fatty acids are
fatty acids, particularly lymphocytes, should be undertaken
important for neural structure and function95 – 101 and this
as well as immunological studies such as T-cell and macro-
aspect may explain studies where improvements in EDSS
phage pro- and anti-inflammatory cytokine gene expression
have also been reported. Furthermore requirements for essen-
and production, T regulatory cells and anti-myelin antibodies.
tial polyunsaturated fatty acids increase as a function of the
In this way a more complete picture will emerge of the clinical
amount of saturated fat in the diet102 and we have recently
and therapeutic significance and the metabolic, immunological
found significant positive correlations between dietary total
and neurological bases to the role of polyunsaturated fatty
saturated and total monounsaturated fatty acids and delta-6
acids in the pathogenesis and treatment of MS.
and delta-5 desaturase gene expression in human PBMC103.
The level of dietary saturated and monounsaturated fattyacids should not therefore be ignored and may be important
Conflict of interest statement
factors in some of the trials discussed above and relate tothe MS epidemiological correlations, mentioned earlier in
BGC20-884 and related intellectual property are patented by
this overview, in relation to an increased requirement for poly-
BTG International Ltd with LSH and MKS as named inven-
unsaturated fatty acids in MS.
tors. LH and MKS co-wrote the manuscript. At the time ofthe trial there were no conflicts of interests. Subsequently tothe trial findings BGC20-884 and related intellectual property
Conclusions and perspectives
is now the subject of patents held by BTG International Ltdwith LSH and MKS as named inventors. LH wrote the text
Taken overall the epidemiological, biochemical, experimental
and MKS was the lead trial neurologist.
animal model and clinical trial data described in this overviewshow that polyunsaturated fatty acids, particularly the n-6 fattyacids, do have a role in the pathogenesis and treatment of mul-tiple sclerosis. We have demonstrated dysregulation of n-6fatty acid metabolism and cytokines in MS and have been
able to show in a small "proof of concept" clinical trial a
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Polycystic Ovarian A Guide for Women IntroductionThis book has been compiled by Douglas Pharmaceuticals Ltd in the interest of providing you, our reader, with a greater understanding of the condition and treatments for Polycystic Ovarian Syndrome. We are grateful for the significant contribution made to the book by a variety of specialists at the Oxford Clinic, Christchurch and others. Whilst their perspectives and understandings are not intended to replace the advice of your own doctor, we do hope that the book proves useful in your own insight into the condition.
GUIDELINES FOR ANTIRETROVIRAL THERAPY IN GHANA National HIV/AIDS/ STI Control Programme Ministry of Health / Ghana Health Service ACKNOWLEDGEMENTS The National HIV/AIDS/STI Control Programme (NACP) wishes to express its extreme gratitude to and to acknowledge the valued input of those listed below whose efforts and contributions were essential in the preparation of this document. We wish to thank The World Health Organisation, Family Health International and the Ministry of Health for providing technical and financial support. We are grateful for the following group of individuals who aided the development of the first edition of the guidelines. Dr. George Amofa