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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
Ewing C & Bernard CC (1998) Insights into the aetiology and
marked therapeutic benefit. Thus we suggest that dysregula-
pathogenesis of multiple sclerosis. Immunol Cell Biol. 76,
tion of n-6 fatty acid metabolism and cytokines is one mech-
anism that is important in disease progression, which is
Noseworthy JH (1999) Progress in determining the causes and
modifiable by specific supplementation. Thus metabolic dis-
treatment of multiple sclerosis. Nature 399, Suppl. 24,
turbance of the production of the long chain n-6 fatty acids
A40 – A46.
Martino G & Hartung H-P (1999) Immunopathogenesis of
DGLA and AA affects the physiological integrity of
multiple sclerosis: the role of T cells. Curr Opin Neurol 12,
immune cells, in that they have a limited ability to produce
309 – 321.
TGF-b, under relapse conditions, which is important for the
Hafler DA (2004) Multiple Sclerosis. J. Clin Invest. 113,
regulation of pro-inflammatory cytokine production e.g.
788 – 794.
TNF-a, IL-1b, IFN-g as well as other cellular biological
Fredrikson S, Soderstrom M, Hillert J, et al. (1994) Multiple
functions. It is also known that TGF-b and fatty acids such
sclerosis: occurrence of myelin basic protein peptide-reactive
Polyunsaturated fatty acids and multiple sclerosis
T cells in healthy family members. Acta Neurol Scand 89,
Maimone D, Reder AT & Gregory S (1993) T cell lympho-
184 – 189.
kine-induced secretion of cytokines by monocytes from
Kerlero de Rosbo N, Milo R, Lees MB, et al. (1993) Reactivity
patients with multiple sclerosis. Cell Immunol 146, 96 – 106.
to myelin antigens in multiple sclerosis. Peripheral blood lym-
Hirsch RL, Panitch HS & Johnson KP (1985) Lymphocytes
phocytes respond predominantly to myelin oligodendrocyte
from multiple sclerosis patients produce elevated levels of
glycoprotein. J Clin Invest 92, 2602 – 8.
gamma interferon in vitro. J Clin Immunol 5, 386 – 389.
Kerlero de Rosbo N, Hoffman M, Mendel I, et al. (1997) Pre-
Hollifield RD, Harbige LS, Pham-Dinh D & Sharief M (2003)
dominance of the autoimmune response to myelin oligodendro-
Evidence for cytokine dysregulation in multiple sclerosis: per-
cyte glycoprotein (MOG) in multiple sclerosis: reactivity to the
ipheral blood mononuclear cell production of pro-inflamma-
extracellular domain of MOG is directed against three main
tory and anti-inflammatory cytokines during relapse and
regions. Eur J Immunol 27, 3059 – 69.
remission. Autoimmunity 36, 133 – 141.
Chou YK, Bourdette DN, Offner H, et al. (1992) Frequency of
Imamura K, Suzumura A, Hayashi F, et al. (1993) Cytokine
T cells specific for myelin basic protein and myelin proteolipid
protein in blood and cerebrospinal fluid in multiple sclerosis.
in multiple sclerosis patients. Acta Neurol Scand 87,
J Neuroimmunol 38, 105 – 114.
281 – 285.
Ota K, Matsui M, Milford EL, et al. (1990) T cell recognition
Philippe J, Debruyne J, Leroux-Roels G, et al. (1996) In vitro
of an immunodominant myelin basic epitope in multiple scler-
TNF-alpha, IL-2 and IFN-gamma production as markers of
osis. Nature 346, 183 – 187.
relapses in multiple sclerosis. Clin Neurol Neurosurg 98,
Burns J, Bartholomew B & Lobo S (1999) Isolation of myelin
286 – 290.
basic protein-specific T cells predominantly from the memory
Bertolotto A, Malucchi S, Capobianco M, et al. (1999) Quan-
T-cell compartment in multiple sclerosis. Ann Neurol 45,
titative PCR reveals increased levels of tumor necrosis factor-
alpha mRNA in peripheral blood mononuclear cells of multiple
Zhang J, Markovic-Plese S, Lacet B, et al. (1994) Increased
sclerosis patients during relapses. J Interferon Cytokine Res 19,
frequency of interleukin 2-responsive T cells specific for
575 – 581.
myelin basic protein and proteolipid protein in peripheral
Beck J, Rondot P, Catinot L, et al. (1988) Increased production
blood and cerebrospinal fluid of patients with multiple scler-
of interferon gamma and tumor necrosis factor precedes clini-
osis. J Exp Med 179, 973 – 984.
cal manifestation in multiple sclerosis: do cytokines trigger off
Tejada-Simon MV, Hong J, Rivera VM, et al. (2001) Reactiv-
exacerbations? Acta Neurol Scand 78, 318 – 323.
ity pattern and cytokine profile of T cells primed by myelin
Sharief MK & Hentges R (1991) Association between tumour
peptides in multiple sclerosis and healthy individuals. Eur J
necrosis factor-alpha and disease progression in patients with
Immunol 31, 907 – 917.
multiple sclerosis. N. Engl. J. Med. 325, 467 – 472.
Bielekova B, Goodwin B, Richert N, Cortese I, Kondo T,
Sharief MK & Thompson EJ (1992) In vivo relationship of
Afshar G, Gran B, Eaton J, et al. (2000) Encephalitogenic
tumor necrosis factor-alpha to blood-brain barrier damage in
potential of the myelin basic protein peptide (amino acids
patients with active multiple sclerosis. J Neuroimmunol 38,
83-99) in multiple sclerosis: results of a phase II clinical
trial with an altered peptide ligand. Nature Medicine 6,
Rieckmann P, Albrecht M, Kitze B, et al (1994) Cytokine
1167 – 1175.
mRNA levels in mononuclear blood cells from patients with
Navikas V & Link H (1996) Review: cytokines and the patho-
multiple sclerosis. Neurology 44, 1523 – 1526.
genesis of multiple sclerosis. J Neurosci Res 45, 322 – 333.
Lu CZ, Jensen MA & Arnason BG (1993) Interferon gamma-
McCarron RM, Wang L, Racke MK, et al. (1993) Cytokine-
and interleukin-4-secreting cells in multiple sclerosis. J
regulated adhesion between encephalitogenic T lymphocytes
Neuroimmunol 46, 123 – 128.
and cerebrovascular endothelial cells. J Neuroimmunol 43,
Bertolotto A, Capobianco M, Malucchi S, et al. (1999) Trans-
forming growth factor beta1 (TGFbeta1) mRNA level corre-
Selmaj K, Raine CS, Farooq M, et al. (1991) Cytokine cytotoxicity
lates with magnetic resonance imaging disease activity in
against oligodendrocytes. Apoptosis induced by lymphotoxin.
multiple sclerosis patients. Neurosci Lett 263, 21 – 4.
J Immunol 147, 1522–1529.
Mokhtarian F, Shi Y, Shirazian D, et al. (1994) Defective pro-
Vartanian T, Li Y, Zhao M, et al. (1995) Interferon-gamma-induced
duction of anti-inflammatory cytokine, TGF-beta by T cell
oligodendrocyte cell death: implications for the pathogenesis of
lines of patients with active multiple sclerosis. J Immunol
multiple sclerosis. Mol Med 1, 732–743.
152, 6003 – 6010.
Kuroda Y & Shimamoto Y (1991) Human tumor necrosis
De Stefano N, Narayanan S, Francis GS, Arnaoutelis R,
factor-alpha augments experimental allergic encephalomyelitis
Tartaglia MC, Antel JP, Matthews PM & Arnold DL (2001)
in rats. J Neuroimmunol 34, 159 – 164.
Evidence of axonal damage in the early stages of multiple
Issazadeh S, Lorentzen JC, Mustafa MI, et al. (1996) Cyto-
sclerosis and its relevance to disability. Arch Neurol. 58,
kines in relapsing experimental autoimmune encephalomyelitis
in DA rats: persistent mRNA expression of proinflammatory
Bjartmar C, Wujek JR & Trapp BD (2003) Axonal loss in the
cytokines and absent expression of interleukin-10 and trans-
pathology of MS: consequences for understanding the pro-
forming growth factor-beta. J Neuroimmunol 69, 103 – 115.
gressive phase of the disease. J. Neuro. Sci. 206, 165 – 171.
Ruddle NH, Bergman CM, McGrath KM, et al. (1990) An
Lassmann H, Bruck W & Lucchinettii C (2001) Heterogeneity
antibody to lymphotoxin and tumor necrosis factor prevents
of multiple sclerosis pathogenesis: implications for diagnosis
transfer of experimental allergic encephalomyelitis. J Exp
and therapy. Trends in Molecular Medicine. 7, 115 – 121.
Med 172, 1193 – 1200.
Matute C & Perez-Cerda F (2005) Multiple sclerosis: novel
Cannella B & Raine CS (1995) The adhesion molecule and
perspectives on newly forming lesions. Trends in Neuro-
cytokine profile of multiple sclerosis lesions. Ann Neurol 37,
sciences 28, 173 – 175.
424 – 435.
Swank RL (1950) Multiple sclerosis: a correlation of its inci-
Merrill JE, Strom SR, Ellison GW, et al. (1989) In vitro study
dence with dietary fat. Am. J. Med. Sci. 220, 421 – 430.
of mediators of inflammation in multiple sclerosis. J Clin
Alter M, Yamoor M & Harshe M (1974) Multiple sclerosis and
Immunol 9, 84 – 96.
nutrition. Arch. Neurol. 31, 267 – 272.
L. S. Harbige and M. K. Sharief
Wolfgram F (1975) Similar geographical distribution of mul-
patients with multiple sclerosis. Acta Neurol Scand 68,
tiple sclerosis and cancer of the colon. Acta. Neurol. Scandi-
362 – 364.
nav. 52, 294 – 302.
Heipertz R, Klauke W, Pilz H & Ritter G (1977) Serum fatty
Agranoff BW & Goldberg D (1974) Diet and the geographical
acids in multiple sclerosis. J. Neurology 214, 153 – 157.
distribution of multiple sclerosis. Lancet, Nov 2 1061 – 1066.
Nightingale S, Woo E, Smith AD, et al. (1990) Red blood cell
Ghadirian P, Jain M, Ducic S, et al. (1998) Nutritional factors
and adipose tissue fatty acids in mild inactive multiple scler-
in the aetiology of multiple sclerosis: a case-control study in
osis. Acta Neurol Scand 82, 43 – 50.
Montreal, Canada. Int J Epidemiol. 27, 845 – 852.
Love WC, Cashell A, Reynolds M & Callaghan N (1974)
Murrell TGC, Harbige LS & Robinson IC (1991) A review of
Linoleate and fatty acid patterns of serum lipids in multiple
the aetiology of multiple sclerosis: an ecological approach.
sclerosis and other diseases. Br Med J 3, 18 – 21.
Ann Hum Biol. 18, 95 – 112.
Jones R & Harbige LS (1987) Erythrocytes in multiple scler-
Malosse D, Perron H, Sasco A & Seigneurin JM (1992) Corre-
osis: effect of increased intake of essential fatty acids on
lation between milk and dairy product consumption and multiple
phosphoglycerides and electrophoretic mobility. In Multiple
sclerosis prevalence: a worldwide study. Neuroepidemiology 11,
Sclerosis, Immunological, Diagnostic and Therapeutic Aspects,
304 – 312.
pp. 201 – 209 [F Clifford Rose and R Jones, editors]. London:
Esparza ML, Sasaki S & Kesteloot H (1995) Nutrition, lati-
John Libbey & Co Ltd.
tude, and multiple sclerosis mortality: an ecologic study. Am.
Harbige LS, Crawford MA, Jones R, Preece AW & Forti A
J. Epidemiol. 142, 733 – 737.
(1986) Dietary intervention studies on the phosphoglyceride
Zhang SM, Willet WC, Hernan MA, Olek MJ & Ascherio A
fatty acids and electrophoretic mobility of erythrocytes in mul-
(2000) Dietary fat in relation to risk of multiple sclerosis
tiple sclerosis. Prog. Lipid Res 25, 243 – 248.
among two large cohorts of women. Am J Epidemiol 152,
Homa ST, Conroy DM, Belin J, Smith AD, Monro JA &
1056 – 1064.
Zilkha KJ (1981) Fatty acid patterns of red blood cell phospho-
Baker RWR, Thompson RHS & Zilkha KJ (1964) Serum fatty
lipids in patients with multiple sclerosis. Lancet, August 29
acids in multiple sclerosis. J Neuro Neurosurg Psychiatry 27,
408 – 414.
Nordvik I, Myhr K-M, Nyland H & Bjerve KS (2000) Effect of
Sanders H, Thompson RH, Wright HP & Zilkha KJ (1968)
dietary advice and n-3 supplementation in newly diagnosed
Further studies on platelet adhesiveness and serum cholesteryl
MS patients. Acta. Neurol Scand 102, 143 – 149.
linoleate levels in multiple sclerosis. J. Neurol. Neurosurg.
Field EJ & Joyce G (1983) Multiple sclerosis: effect of
Psychiat. 31, 321 – 325.
gamma-linolenate administration upon membranes and the
Gul S, Smith AD, Thompson RHS, et al. (1970) Fatty acid
need for extended clinical trials of unsaturated fatty acids.
composition of phospholipids from platelets and erythrocytes
Eur. Neurol. 22, 78 – 83.
in multiple sclerosis. J Neurol Neurosurg Psychiat 33,
Field EJ, Joyce G & Smith BM (1977) Erythrocyte-UFA
506 – 510.
(Eufa) mobility test for pathogenesis and handling of the dis-
Thompson RHS (1973) Fatty acid metabolism in multiple
ease. J Neurol 214, 113 – 127.
sclerosis. Biochemical Society Symposium 35, 103 – 111.
Harbige LS (2003) Fatty acids, the immune response, and auto-
Thompson RHS (1975) Unsaturated fatty acids in multiple
immunity: a question of n-6 essentiality and the balance
sclerosis. In Multiple Sclerosis Resaerch, pp. 184 – 193 [AN
between n-6 and n-3. Lipids 38, 323 – 341.
Davison, JH Humphrey, AL Liversedge, WI McDonald and
Meade CJ, Mertin J, Sheena J & Hunt R (1978) Reduction by
JS Porterfield, editors]. USA, Elsevier: North Holland.
linoleic acid of the severity of experimental allergic encepha-
Tsang WM, Belin J, Monro JA, Smith AD, Thompson RHS &
lomyelitis in the guinea-pig. J Neuro Sci 35, 291 – 308.
Zilkha KJ (1976) Relationship between plasma and lympho-
Mertin J & Stackpoole A (1978) Suppression by essential fatty
cyte linoleate in multiple sclerosis. J Neurol Neurosurg Psy-
acids of experimental allergic encephalomyelitis is abolished
chiatry 39, 767 – 771.
by indomethacin. Prostaglandins and Medicine 1, 283 – 291.
Homa ST, Belin J, Smith AD, et al. (1980) Levels of linoleate
Harbige LS, Yeatman N, Amor S & Crawford MA (1995) Pre-
and arachidonate in red blood cells of healthy individuals and
vention of experimental autoimmune encephalomyelitis in
patients with multiple sclerosis. J Neurol Neurosurg Psychiat
Lewis rats by a novel source of g-linolenic acid. Br J Nutr
43, 106 – 110.
74, 701 – 715.
Neu IS (1983) Essential fatty acids in the serum and cerebrosp-
Harbige LS, Layward L, Morris-Downes MM, et al. (2000) The
inal fluid of multiple sclerosis patients. Acta. Neurol. Scand.
protective effects of omega-6 fatty acids in experimental auto-
67, 151 – 163.
immune encephalomyelitis (EAE) in relation to transforming
Cherayil GD (1984) Sialic acid and fatty acid concentrations in
growth factor-beta 1 (TGF-beta1) up-regulation and increased
lymphocytes, red blood cells, and plasma from patients with
prostaglandin E2 (PGE2) production. Clin Exp Immunol 122,
multiple sclerosis. J Neuro Sci. 63, 1 – 10.
445 – 452.
Fisher M, Johnson MH, Natale AM, et al. (1987) Linoleic acid
Adda DH, Beraud E & Depieds R (1977) Evidence for suppressor
levels in white blood cells, platelets and serum of multiple
cells in Lewis rats' experimental allergic encephalomyelitis.
sclerosis patients. Acta Neurol Scand 76, 241 – 245.
Eur J Immunol 7, 620 – 623.
Navarro X & Segura R (1989) Red blood cell fatty acids in
Karpus WJ & Swanborg RH (1991) CD4þ suppressor cells
multiple sclerosis. Acta Neurol Scand 79, 32 – 37.
inhibit the function of effector cells of experimental auto-
Holman RT, Johnson SB & Kokmen E (1989) Deficiencies of
immune encephalomyelitis through a mechanism involving
polyunsaturated fatty acids and replacement by nonessential
transforming growth factor-b. J Immunol 146, 1163 – 1168.
fatty acids in plasma lipids in multiple sclerosis. Proc. Natl.
Rack MK, Sriram S, Calrlini J, Cannella B, Raine CS &
Acad. Sci. USA. 86, 4720 – 4724.
McFarlin DE (1993) Long-term treatment of chronic relapsing
Shukla VKS & Clausen J (1978) Linoleate and fatty acid pat-
terns of serum lipids in multiple sclerosis. Acta. Neurol. Scan-
growth factor-b2. J Neuroimmunol 46, 175 – 183.
dinav 57, 270 – 274.
Santambrogio L, Hochwald GM, Saxena B, Leu CH, Martz JE,
Yoshida M, Takase S, Itahara K & Nakanishi T (1983) Linole-
Carlino JA, Ruddle NH, Palladino MA, Gold LI & Thorbecke
ate and fatty acid compositions in the serum lipids of Japanese
GJ (1993) Studies on the mechanisms by which Transforming
Polyunsaturated fatty acids and multiple sclerosis
Growth Factor-b protects against allergic encephalomyelitis.
Birch EE, Garfield S, Castaneda Y, Hughbanks-Wheaton D,
J Immunol 151, 1116 – 1127.
Uauy R & Hoffman D (2007) Visual acuity and cognitive
Ovadia H & Paterson PY (1982) Effect of indomethacin treat-
outcomes at 4 years of age in a double-blind, randomized
ment upon actively-induced and transferred experimental aller-
trial of long-chain polyunsaturated fatty acid-supplemented
gic encephalomyelitis (EAE) in Lewis rats. Clin Exp Immunol
infant formula. Early. Hum. Dev. 83, 279 – 284.
49, 386 – 392.
Martinez M, Vazquez E, Garcia-Silva MT, et al. (2000) Thera-
Liblau RS, Singer SM & McDevitt (1995) Th1 and Th2
peutic effects of docosahexaenoic acid ethyl ester in patients
CD4þT cells in the pathogenesis of organ-specific autoimmune
with generalized peroxisomal disorders. Am. J. Clin. Nutr 71,
diseases. Immunology Today 16, 34 – 38.
Suppl, 376S – 85S.
Khoury SJ, Hancock WW & Weiner HL (1992) Oral tolerance
Crawford MA, Costeloe K, Ghebremeskel K, et al. (1997) Are
to myelin basic protein and natural recovery from experimental
deficits of arachidonic and docosahexaenoic acids responsible
autoimmune encephalomyelitis are associated with downregu-
for the neural and vascular complications of preterm babies.
lation of inflammatory cytokines and differential upregulation
Am. J. Clin. Nutr. 66, Suppl, 1032S – 41S.
of transforming growth factor b, interleukin 4, and prostaglan-
Xiang M, Alfven G, Blennow M, Trygg M & Zetterstrom R
din E expression in the brain. J Exp Med 176, 1355 – 1364.
(2000) Long chain polyunsaturated fatty acids in human milk
Bates D, Fawcett PRW, Shaw DA & Weightman D (1978)
and brain growth during early infancy. Acta Paediatr 89,
Polyunsaturated fatty acids in the treatment of acute remitting
142 – 147.
multiple sclerosis. Br Med J. 2, 1390 – 1391.
De la Pressa Owens S & Innis SM (2000) Diverse, region
Millar JHD, Zilkha KJ, Langman MJS, Payling-Wright H, et al.
specific effects of addition of arachidonic and docosahexaenoic
(1973) Double-blind trial of linoleate supplementation of the
acids to formula with low or adequate linoleic and alpha-lino-
diet in multiple sclerosis. Br Med J 1, 765 – 768.
lenic acids on piglet brain monoaminergic neurotransmitters.
Paty DW, Cousin HK, Read S & Adlakha K (1978) Linoleic
Pediatr Res 48, 125 – 130.
acid in multiple sclerosis: failure to show any therapeutic
Conklin SM, Gianaros PJ, Brown SM, et al. (2007) Long-chain
benefit. Acta Neuro Scand 58, 53 – 58.
omega-3 fatty acid intake is associated positively with cortico-
Dworkin RH, Bates D, Millar JHD, et al. (1984) Linoleic acid
limbic grey matter volume in healthy adults. Neurosci Lett
and multiple sclerosis: a reanalysis of three double blind trials.
421, 209 – 212.
Neurology 34, 1441 – 1445.
Holman RT (1960) The ratio of trienoic: tetraenoic acids in
Bates D, Cartlidge NEF, French JM, et al. (1989) A double-
tissue lipids as a measure of essential fatty acid requirements.
blind controlled trial of long chain n-3 polyunsaturated fatty
J. Nutr 70, 405 – 410.
acids in the treatment of multiple sclerosis. J Neurol Neuro-
Xiang M, Rahman MA, Ai H, Li X & Harbige LS (2006) Diet
surg Psychiatry 52, 18 – 22.
and gene expression: delta-5 and delta-6 desaturases in
Swank RL (1970) Multiple sclerosis: twenty years on a low fat
healthy Chinese and European subjects. Ann Nutr Metab 50,
diet. Arch. Neurol. 23, 460 – 474.
492 – 498.
Fitzgerald G, Harbige LS, Forti A & Crawford MA (1987) The
Sinclair AJ & Crawford MA (1972) The accumulation of ara-
effect of nutritional counselling on diet and plasma EFA status
chidonate and docosahexaenote in the developing rat brain.
in multiple sclerosis patients over 3 years. Numan Nutrition:
J. Neurochem 19, 1753 – 1758.
Applied Nutrition, 41A, 297 – 310.
Merrill JE & Zimmerman RP (1991) Natural and induced cyto-
Swank RL & Grimsgaard A (1988) Multiple sclerosis: the lipid
toxicity of oligodendrocytes by microglia is inhibitable by
relationship. Am. J. Clin. Nutr 48, 1387 – 1393.
TGF beta. Glia 4, 327 – 331.
Swank RL & Dugan BB (1990) Effect of low saturated fat diet in
Copeland C, Curzner ML, Groome N & Diemel LT (2000)
early and late cases of multiple sclerosis. Lancet, July 7 336, 37–39.
Temporal analysis of growth factor mRNA expression in mye-
Harbige LS, Jones R, Jenkins R, Fitzgerald G, Forti A &
linating rat brain aggregate cultures: increments in CNTF,
Budowski P (1990) Nutritional management in multiple scler-
FGF-2, IGF-I, and PDGF-AA mRNA are induced by anti-
osis with reference to experimental models. Ups J Med Sci 48,
body-mediated demyelination. Glia 30, 342 – 351.
189 – 207.
Serafina S, Sanchez M, Campeggi L, Suchanek G, Breitschop
Harbige LS, Hollifield RD, Pinto E, Xiang M, Leach M & Sharief
H & Lassmann H (1996) Accelerated myelinogenesis by
MK (2007) Polyunsaturated fatty acids (n-6) in the treatment and
dietary lipids in rat brain. Journal Neurochemistry 67,
pathogenesis of multiple sclerosis: ii results of a randomised,
1744 – 1750.
double blind, placebo controlled trial for. Lancet.
Van Meeteren ME, Baron W, Beermann C, Dijkstra CD &
Neuringer M, Anderson GJ & Conner WE (1988) The essenti-
van Tol EA (2006) Polyunsaturated fatty acid supplementation
ality of n-3 fatty acids for the development and function of the
stimulates differentiation of oligodendroglia cells. Dev Neurosci
retina and brain. Ann. Rev. Nutr. 8, 517 – 541.
28, 196 – 208.
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