The current study revealed a high prevalence of overweight, obesity and central obesity among the enrolled 120 patients close to that reported for MS patients in the same unit before . The prevalence of overweight and obesity is higher than that reported by Marck et al., . Mean waist circumference is also higher than that reported by Drehmer E et al,  thus indicating a higher risk of metabolic complications. The observed higher prevalence in the current study can be attributed to the overconsumption of macronutrients, low intake of dietary fibers and the sedentary nature of most of the patients. The mean 24-hour energy, carbohydrates, proteins and fat consumption was higher in our study than that reported by Armon-Omer et al  which together with lower fiber intake account for the difference in mean BMI between the two studies (27.7 ± 5.7 kg/m2 and 25.0 ± 4.4 kg/m2 respectively). Dietary fibers were consumed at less than the acceptable levels by our patients (8.7 ± 4.6 g/day in all enrolled patients, 8.0 ± 4.1 in females and 10.6 ± 5.2 in males) as the 2020–2025 Dietary Guidelines recommend 22–28 g for women and 28–34 g for men over the age of 19 . Most of the studied patients described their daily efforts as light or very light and more than three quarters of the patients did not practice sports.
The prevalence of underweight among enrolled MS patients was low. Only 1.7% of the CG group was underweight (BMI less than 18.5 kg/m2). Most enrolled patients (88.3%) were at low risk of malnutrition according to MUST scores (93.3% in IG and 83.3% in the CG). Weight loss is known to occur in advanced MS. In our study, patients were at a relatively early stage of the disease as most of them were suffering from RRMS.
Regarding micronutrients, the intake of sodium, potassium, calcium, phosphorous, magnesium, iron, zinc, copper and vitamins A, C, B1 and B2 intake was comparable in the IG and CG in pre-counselling assessment (p > 0.05). Those intakes were lower than the RDA for all nutrients except sodium which was much higher, phosphorous and copper which were slightly higher . The lower intake of calcium, magnesium, zinc, and iron was in consistency with Armon-Omer et al . Sodium was consumed in very large amounts by patients of both IG and CG (3222.7mg and 3274.8 mg/day respectively). This was higher than the 2300 mg recommended by 2020–2025 Dietary Guidelines for people older than 19 years . Also, it was higher than the mean sodium intake reported in the Armon-Omer et al. study (2392.66 mg) . Kleinewietfeld mentioned that increased dietary salt intake might be an environmental risk factor for the development of autoimmune diseases by inducing pathogenic cells and related proinflammatory cytokines . Those cells have been involved in the development of MS . Fitzgerald KC et al,  based on multiple assessments of urine sodium excretion over 5 years and standardized clinical and MRI follow-up, suggested that salt intake does not influence MS disease course or activity. Even though the evidence linking high salt intake and MS is contradictory, combining the DASH diet with low sodium intake might be beneficial in MS. It also improves the vascular health of MS patients .
In order to identify the effect of nutrition counselling on the nutritional status of KAMSU patients this randomized controlled clinical trial was carried out. This design is the gold standard for measuring the effectiveness of a new intervention or treatment. Blinding of patients and health care providers was not possible due the nature of intervention; however, we blinded the statistician who analyzed the data. Nutrition counselling was provided by a specialized nutritionist and follow up was optimized through phone calls and WhatsApp messaging. About 78.9% and 89.3% of IG and CG patients were compliant with the prescribed regimens as reported in the final assessment. The lower compliance rate among the IG compared to the CG may be attributed to the patient’s readiness to adopt healthy dietary behavior.
The current trial revealed that nutrition counselling significantly helped MS patients achieve a healthier weight, better waist circumference, macronutrient intake and adequacy compared to those in the control arm. The PPA highlighted the significant change in the compliant male’s waist circumference (p = 0.043) in contrast to the insignificant change revealed by the ITTA. (p = 0.280). Also, the PP analysis showed that more weight was lost by compliant overweight and obese patients after the exclusion of non-compliers who diluted the change observed in the ITT analysis.
Following counseling, the risk of malnutrition, the prevalence of obesity and the prevalence of patients who were at substantially increased risk of metabolic complications decreased in males and females. The changes in the percentages of the different BMI categories were not significant in both the ITT and PP analyses. After controlling for the initial BMI categories, there was a significant difference between the outcomes of obese patients in the IG and CG (p = 0.025). The observed effect is attributed to the improved food intake, less sedentary hours and more activity induced by counseling.
Regarding nutrition supplementation, the most recent ESPEN guidelines on clinical nutrition in neurology did not recommend routine supplementation for MS patients, but rather to correct established deficiencies . In the pre- and postintervention assessments, vitamin and mineral supplements were taken by ≥ 60% of the IG and CG patients (60% and 70% pre and 63.2% and 65.5% post-counselling respectively). Similar findings were reported in an American study where 68.6% of the studied MS patients consumed vitamin and mineral supplements . Higher frequency of supplement intake was even reported in a Danish study conducted on 967 MS patients (78.5%) . Nutrition counseling did not affect supplement intake in our study as it was initially high and continued to be so because patients were taking it as a part of the standard management at KAMS unit.
Nutrition counseling induced considerable improvement in fiber intake in the IG from 8.6 ± 5.2 g to 21.0 ± 8.3g (p = 0.000), the level of intake of both males (27.0g) and females (20.9g) became close to the minimum recommended. Extra emphasis needs to be addressed regarding eating fiber rich foods.
Counselling did not improve the intake of macronutrients only, but it did improve the intake of micronutrients as well. ANCOVA analysis revealed a significant increase in the consumption of potassium, magnesium, and vitamin C; decrease in the consumption of sodium, phosphorus and zinc (p < 0.05). The percentage of IG patients who consumed acceptable amounts of magnesium and iron increased significantly over the percent in CG. Similarly, the percentages of IG patients who consumed unsafe and unacceptable amounts of vitamin C, B1 and B2 had decreased. Impairments of micronutrient intake might be of clinical significance in MS as they contribute to existing symptoms such as muscle wasting, weakness, fatigue, and muscle spasms . Counseling appears to ameliorate the effect of many of these impairments.
The effect of counseling on nutrient intake can be explained by the changes in food intake of patients. Patients in the intervention group significantly improved their consumption from the food groups into a healthier one. They increased their intake of milk, vegetables and fruits and decreased their intake of grains, added sugar and fat (p < 0.05). Milk is an excellent source of many vitamins and minerals, including vitamin B12, calcium, riboflavin, and phosphorus. It’s often fortified with other vitamins, especially vitamin D .
Vegetables and fruits are good sources of vitamins and minerals including vitamin C, carotene, calcium, iron and potassium . They are good sources of magnesium and fiber and are usually low in fat and calories.
Eating a variety of vegetables and fruits clearly ensures an adequate intake of most micronutrients, dietary fibers and a host of essential non-nutrient substances. As well, increased fruit and vegetable consumption can help displace foods high in saturated fats, sugar or salt. A healthy diet includes at least 400 g (i.e. five portions) of fruit and vegetables per day, excluding potatoes, sweet potatoes and other starchy roots .
In conclusion, overweight, obesity, abdominal obesity and faulty dietary habits are prevalent among the MS patients attending KAMSU. Nutrition counselling significantly improved eating and activity pattern of MS patients into a healthier pattern, it helped patients achieve better weight, waist circumference, nutrient intake and adequacy compared to those in the control arm who did not receive the counseling. Accordingly, nutritional counselling and care must be considered an integral part of the health care of MS patients at KAMSU and elsewhere.
The current study findings should be interpreted considering the following limitations: First, the 24-hour dietary recall may have some weaknesses, such as recall bias, inaccurate estimation of portion sizes, possible over/under-reporting of certain foods, and that data from a single day cannot accurately represent the respondent’s usual intake. One of the researchers, who is a ESPEN-qualified clinical nutrition specialist, conducted all interviews herself to ensure good quality of data. Also, the 24-hour dietary recall was complemented by other tools of nutritional assessment, such as anthropometric and clinical. Secondly, the compliance rate among the intervention group (78.9%) was lower than that of the control group (89.3%). The patient’s readiness to adopt healthy dietary behaviour is an important factor to take into consideration.