Dietary Supplements in Combination with Conventional Medicine among People with Multiple Sclerosis

Despite recent advances in immune-modulatory drugs, pharmacological therapies have been proven ineffective in severe presentations of multiple sclerosis (MS), including secondary progressive MS. At present, therapeutic interventions' performance is primarily focused on ameliorating symptoms to improve the patient's quality of life. Among complementary treatments, nutrition has been considered a decisive factor to control symptoms and enhance the wellness of MS patients. Although no special diets are associated with MS, the impact of diet and dietary supplements on the course of progressive forms of the disease have been studied during the last years. Fatigue is among the most common and disabling symptoms reported by MS patients. Fatigue has been defined in the Multiple Sclerosis Council for Clinical Practice Guidelines (MSCCPG, 1998) as a "subjective lack of physical and/or mental energy that the individual perceives as an interference with habitual and desired activities". This study aimed to compare the psychometric functioning of the "Fatigue Severity Scale" (FSS) and the "Modified Fatigue Impact Scale" (MFIS) in our sample of people with MS. Specifically, during chronic treatment, the change in these two parameters with two vitamin-rich dietary supplements (Citozym® and Ergozym®) was evaluated. The impact of these nutritional supplements revealed differences in antioxidant and anti-inflammatory parameters between treatment groups with subsequent improvement in fatigue. In conclusion, the results obtained have confirmed the effectiveness of complementary nutritional therapies, evaluated essentially based on hematological biomarkers, through which it is possible to act on disability to improve the quality of life of MS patients.

the limited range of treatments available [5]. Similarly, the impact of dietary intervention on inflammation can be enhanced by supplements with intense antioxidant activities. Despite current therapies aimed at improving the disease, poor quality of life in MS patients remains a significant problem, and fatigue is one of the common and disabling symptoms [6]. Patients with MS have significantly reduced quality of life compared with the general population. Some studies have reported that reduced quality of life may be partly the consequence of neurological disability. Fatigue represents the most frequent and disabling symptom among patients with MS, markedly interfering with daily life. Primary fatigue's pathophysiology remains unknown, but undoubtedly, inflammation-related, OS and immunologic factors play a central role. The treatment of this symptom to improve the quality of life presently remains a challenge.
Disability, depression, and fatigue are independent predictors of life quality in people with MS [6]. Fatigue is one of the most common symptoms of multiple sclerosis and may even be the first sign of the disease. Fatigue affects between 75 and 95% of patients; it is not strictly correlated with gender, race, and education. It is considered by 55-75% of patients as one of the most disabling symptoms [7]. However, its diagnosis is not easy because it represents a subjective state, difficult to describe and understood by others. It interferes with the person's physical and mental activities with MS and contributes to worsening the difficulties already present, negatively affecting life quality.
Fatigue can have a psychological impact on the person, especially when fatigue and lack of strength make it harder to perform even the simplest tasks.
Effective treatment options for fatigue remain limited. In this observational study was noted that, among the multiple symptoms of volunteers with MS, fatigue was one of the most painful complaints that patients may experience throughout their lives. The pathogenesis of fatigue and its primary causes remains obscure, and there are currently no adequate therapies. One of the main obstacles to understanding this symptom was the absence of a measurement method universally accepted, that could quantify an experience properly, often disabling and elusive.
Without a measurement, progress in fatigue therapy remained limited. Currently, this limitation has been overcome employing two assessment methods [8], such as the psychometric functioning of "Fatigue Severity Scale" (FSS) and the "Modified Fatigue Impact Scale" (MFIS), which is part of the Multiple Inventory Quality of Life (MSQLI), a battery consisting of 10 individual scales providing a quality of life measure that is both generic and MS-specific [9].
Several factors could contribute to fatigue development and/or exacerbation, and this requires careful work-up to search for all possible underlying causes, such as sleep disorders, endocrine dysfunction and mood disorders, to name a few. Central fatigue is described as fatigue not from the muscle itself but rather from the central nervous system (CNS) and the transmission of signals from the brain to the muscle [6]. Therefore, central fatigue is related to the brain and spinal cord [10].
Nutrition is considered a possible factor in the pathogenesis of MS. Current studies in nutritional interventions suggest that diet may be regarded as a complementary treatment to control disease progression [11]. Although several observational studies have demonstrated a relationship between specific dietary patterns and the prevalence of MS, very few have shown a correlation of the diet with fatigue and quality of life, and even fewer have correlated This observational study was conducted on 60 MS patients to determine the therapeutic and protective effects of two commercial dietary supplements called Citozym® and Ergozym® ,(Citozeatec Italy-FDA registration 12932524008 Pin n. bfJ3h263). The two nutritional supplements contain vitamins C, B5, D, B9 (Citozym®), A,B5, B2,B3,B6,B9,B12 (Ergozym®). A total of 60 volunteers with a "Kurtzke Extended disability status score" (EDSS) of less than 6 were recruited for the study, with a definitive diagnosis of relapsing-remitting form of MS. The EDSS is widely used to measure and assess the clinical characteristics of multiple sclerosis patients. It is also a widely accepted tool in clinical trials, for example, to assess the effect of treatments on disease progression [12]. The total EDSS score is determined by two factors: walking ability and scores for eight functional systems. A subscale is used that assesses the functional status of certain functional systems that are variably affected by the disease. 30 volunteers were treated for 70 days according to an experimental nutritional protocol (see supplemental material), and 30 were treated using a placebo preparation made with distilled water, honey, and permitted food pigments, with the same color as that of Citozym® and Ergozym® and considered as a negative control. The age ranged from 30 to 50 years, and the sex was predominantly female (the number of women with multiple sclerosis is almost three times that of men). Demographic and anthropometric characteristics expressed as mean and standard deviation were collected from the patients' medical history (Table I).

Values expressed as an average ± Standard Deviation
Fatigue symptoms were quantified using the psychometric tests FSS and MFIS [13]. Items on the MFIS can be aggregated into three subscales (physical, cognitive, and psychosocial) and a total MFIS score. All items are scaled so that higher scores indicate a more significant impact of fatigue on a person's activities. In this experimental trial, only the physical and total MFIS scores were considered. Written informed consent was obtained from all study participants. The study was reviewed and approved by the board of the "CRSC" Research Institute, under protocol No.
"AB2745P28" on 25 January 2020 as part of the "Dietary Supplementation Project". Patients with secondary or primary progressive MS, pregnancy, corticosteroid treatment, or who simultaneously suffered from another chronic disease such as rheumatic disease, severe heart disease, malignant cancers, and other neurologic and inflammatory diseases were excluded. Patients were advised not to discontinue their routine medications. Written informed consent was completed before the study for all patients. No specific blood tests are available for the diagnosis of MS. However, after the patient's objective examination and history, a series of blood tests were prescribed with a view to a differential diagnosis, the purpose of which was not to confirm the presence of MS but to check the inflammatory status and OS levels to preclude the presence of diseases whose symptoms might overlap with those of MS.

Processing and analysis of blood samples.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 11 May 2021 doi:10.20944/preprints202105.0245.v1 Venous blood sampling was performed according to "WHO Guidelines on Drawing Blood, 2010". Whole blood was immediately centrifuged at 500×g for 20 min after collection. Venous blood samples (5 mL) were collected at the beginning and weekly during the treatment. Serum was separated and aliquots were stored at -80 • C. The total antioxidant status (TAS), superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) activities were determined by previously reported method [14,15]. Several routine blood parameters were monitored (blood glucose, total cholesterol, triglycerides, total lipids, albumin, creatinine, retinol-binding protein (RBP), and C-reactive protein (CRP). Measurement was accomplished through the CBC test using Cell Counter Sysmex XP-300 model (Sysmex, Kobe, Japan) and chemiluminescence microparticle immunoassay/Abbott biochemical method using Abbott IMX kits with Abbott IMx® unit (Abbott Diagnostics, Lake Forest, IL, USA).

Statistical analysis
The statistical analysis was performed using SPSS software (ver. 14.0; SPSS Inc., Chicago, IL). The data were expressed as average ± standard deviation (SD). The differences in clinical and biochemical variables between pre and post within each intervention group with normal distribution were analyzed using the coupled t-test. The statistical significance was defined as p < 0.05.

Values expressed as average ± Standard Deviation
The symptom of fatigue was examined to assess treatment effectiveness with the two nutritional supplements, using the FSS and MFIS tests. As with the FSS, a higher score in the MFIS means that fatigue has a more significant impact on the patient's life. FSS is a self-report scale of nine items about fatigue, its severity and how it affects certain activities. Responses are rated on a seven-point scale where 1 = strongly disagree and 7 = strongly agree [16]. Thus, the minimum possible score is 9, and the maximum is 63. The FSS test administered, to patients, to assess the impact of fatigue in their daily activities was performed at intervals during the administration of the two nutritional  As is well known, the MIFS scale is divided into three subscales: physical, cognitive and psychosocial [17]. To highlight the fatigue aspect, the physical subscale was compared with the total MIFS score. From Figure 2 it is possible to observe how much the physical score has affected the total MIFS score. Fatigue reduction reached and remained during the 70-day treatment period approximately 46% lower than control, similarly to that observed for the total MIFS score reduction (35%). This data suggests how much the symptom fatigue can influence the psychosocial and cognitive aspect of MS patients.

Discussion
This study explored the effects of a multivitamin nutritional treatment, in patients with a definitive diagnosis of control. Among complementary treatments, nutrition has been considered a decisive factor to control symptoms and improve the well-being of MS patients [18]. Although there are no particular diets associated with MS, the impact of diet and dietary supplements on the course of progressive forms of the disease has been studied in recent years [19]. deficiency, characterized by low bone mass and high fracture rates [21]. Notably, it has been suggested that increased serum concentrations of vitamin D, a potent immune-modulator, may reduce the risk of MS [22]. Experimental evidence has also shown that serum vitamin D concentrations are lower during MS relapses than in remission and are associated with a greater degree of disability [11]. Additional evidence reports that circulating vitamin D can be considered a biomarker of MS and recommends vitamin D administration for therapeutic purposes [23]. Vitamin D shows significant anti-inflammatory effects. Some studies have reported a possible association between OS markers and vitamin D level [24], concluding that vitamin D supplementation could reduce the levels of OS markers [25]. The antioxidant effect of vitamin D seems to have a protective role on neurons and could alleviate MS progression [26].
Vitamin A supplementation as a therapeutic possibility for MS has been investigated [27] for its proven benefits at a cellular level [28,29] . Several pieces of evidence suggest that inadequate levels of vitamin A result in the organism's inability to maintain the normal balance of the T-cell subgroups, [30] as well as a negative correlation between serum vitamin A and the development of the disease; because the plasmatic level of vitamin A is lower in patients with MS. [31,32] A cohort study suggested an inverse association of vitamin A levels in serum and the activity of relapsing-remitting MS employing magnetic resonance imaging. [33].  Ascorbic acid (vitamin C) is essential for several physiological processes in the human body. It is present in high concentration in the brain, particularly in the central nervous system (CNS), promoting oligodendrocyte generation and remyelination [42]. Ascorbate recycling by astrocytes and neuronal uptake are essential mechanisms to restore or maintain redox homeostasis under oxidative conditions. Neuronal and glial cells are susceptible to OS, and neurons appear to be particularly sensitive to vitamin C deficiency. In demyelinating diseases, such as MS, myelin sheaths are damaged, and the remyelination process is somewhat hampered. Restoration of myelin sheaths requires differentiation of oligodendrocyte precursor cells into mature oligodendrocytes [42]. Since the production of reactive oxygen species is increased in inflammatory and demyelinating diseases such as MS, as a response to the failure of cellular detoxification and antioxidant mechanisms, the results presented in this report would suggest a reduction of oxidative damage operated by the nutritional therapy adopted. Concerning this, it was possible to observe that the