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Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 200-205

Dietary Factors Associated with Multiple Sclerosis Risk in Kuwait

1 Human Genetics Unit, Department of Pathology, College of Medicine, Kuwait University, Jabriya, Kuwait
2 Neurology Clinic, Al-Amiri Hospital, Kuwait City, Kuwait

Date of Submission11-Apr-2022
Date of Decision12-Jun-2022
Date of Acceptance14-Jun-2022
Date of Web Publication3-Oct-2022

Correspondence Address:
PhD Rabeah Abbas Al-Temaimi
Associate Professor, Human Genetics Unit, Department of Pathology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnpnd.ijnpnd_13_22

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Context: Multiple sclerosis (MS) is a complex disorder of the central nervous system in which gene–environment interactions result in autoimmune targeting of neuronal myelin. In Kuwait, the rapid increase in MS prevalence is in tandem with evident changes in diet and lifestyle habits. Aim: To assess dietary and lifestyle habits of 128 MS patient during their preadult years in comparison to 211 Kuwaiti healthy controls. Methods: A questionnaire inclusive of demographics, lifestyle, and dietary habits in preadult years was administered to MS patients and healthy controls. Results: We found an increased risk of MS in the Kuwaiti adult life is associated with a positive family history and poor preadult dietary habits inclusive of low fresh fruit and vegetable consumption and increased processed food intake. Whereas, passive smoking, preadult weekly physical activity, adolescence milk and fish consumption, and childhood prepacked snacks consumption did not differ between MS and healthy controls. Conclusion: Sudden shifts in dietary habits of the Kuwaiti population in the past two decades have contributed to the increased prevalence of MS in Kuwait. Current management recommendations of MS disease should consider the inclusion of a plant-based, minimally processed dietary regimen in conjunction with MS disease modifying treatments.

Keywords: Diet, Kuwait, lifestyle, multiple sclerosis, risk factor

How to cite this article:
Al-Temaimi RA, Alroughani R. Dietary Factors Associated with Multiple Sclerosis Risk in Kuwait. Int J Nutr Pharmacol Neurol Dis 2022;12:200-5

How to cite this URL:
Al-Temaimi RA, Alroughani R. Dietary Factors Associated with Multiple Sclerosis Risk in Kuwait. Int J Nutr Pharmacol Neurol Dis [serial online] 2022 [cited 2022 Nov 29];12:200-5. Available from:

   Introduction Top

Multiple sclerosis (MS) is a neurodegenerative, autoimmune, and multifactorial disorder in which environmental and genetic factors interact, resulting in disease initiation and manifestation. MS pathogenesis involves self-immune cells recognizing self-myelin proteins as antigens and eliciting a targeted immune response in the central nervous system. These autoimmune reactions result in focal destruction of neurons known as MS plaques, and perturbation of neuronal signal transmission to different parts of the body. These attacks can resolve and never occur again, or may relapse after a period of remission, or may be progressive. A single isolated attack is referred to as a clinically isolated syndrome. Based on the disease clinical course, three MS subtypes have been recognized: relapsing-remitting MS, secondary progressive MS, and primary progressive MS. The current understanding is that MS etiology exhibits genetic heterogeneity contributed by interplay of genetic and environmental factors. MS exhibits many aspects of hereditary disease such as familial transmittance and anticipation.[1] However, sporadic forms of MS are creating an exponential burden suggesting environmentally triggered MS forms in genetically susceptible individuals.[2] Genetic risk factors reported so far do not fully explain MS etiology.[3] The most significant association was reported for polymorphisms in HLA-DRB1 alleles albeit the association was variable among populations.[4] Environmental factors have also been shown to be equally important in dictating MS prevalence and geographic distribution, as well as some aspects of its clinical course and disability progression.[5] Latitude and longitude patterning which relate to insufficient sunlight exposure and vitamin D deficiency,[6] cigarette smoking, and viral infections are well-established environmental risk factors for MS.[7] Diet among other environmental factors, especially in formative or developmental years contributes substantially to immune fitness and competence as well as the overall health of the human body. There are many phases of immune system development and changes throughout the human lifespan that are dictated by environmental exposures to pathogenic, chemical, and dietary factors.[8]

In MS, dietary habits that include high animal fat diet, high salt, and high sugar diets are controversially argued to have pro-inflammatory effects in susceptible individuals exacerbating MS symptoms.[9] In Kuwait, MS prevalence has starkly increased in the past two decades in comparison to previous prevalence estimates.[10],[11] Therefore, the Kuwaiti MS population is young in comparison to MS populations from countries where MS has been reported to be prevalent since the 20th century.[12] The effect of cultural globalization in the 21st century has impacted diet and lifestyle habits in Kuwait, more specifically the adoption of “Western diets” that has been shown to be involved in MS pathogenesis by altering gut microbiota.[13] Human gut microbiota is a mixture of microorganisms inclusive of bacteria, archaea, and fungi that live and thrive the gastrointestinal tract of the human body. These microorganisms provide critical functions to human health as they can confer resistance to pathogens, protect intestinal epithelium lining and continuity, metabolize and ferment indigestible dietary nutrients and pharmaceutical compounds, control and modulate the immune system, and may even impact the gut–brain axis imposing behavioral alterations.[14] The composition of gut microbiota of healthy individuals is in a relative balance; however, any external factors that may disrupt this balance favoring one microorganism against another will ultimately have multisystemic effects including the immune system.[15] The imbalance of gut microbiota is called dysbiosis and we hypothesize that a prolonged state of dysbiosis of the gut microbiota during formative years of an individual contributes to the risk of MS in genetically susceptible individuals, not just the exacerbation or relapse of MS. Therefore, here, we present our results of a survey conducted to assess childhood and adolescence dietary habits of Kuwaiti MS patients relative to healthy controls to identify their association with MS risk.

   Materials and Methods Top

Study protocols were approved by Kuwait University Health Sciences Center’s Joint Committee for the protection of human subjects in research (VDR/JC/883) and by Dasman Diabetes Institute ethical review committee (RA/018/2013); both of which adhere to the Declaration of Helsinki − Ethical Principles for Medical Research Involving Human Subjects Guidelines. All patients and healthy controls included in this study gave their written consent to participate in this study. Kuwaiti MS patients were recruited at Dasman Diabetes Institute’s MS clinic, while healthy controls were recruited from the general Kuwaiti population through social media questionnaire posting. MS patients were selected based on the following criteria: a confirmed MS clinical diagnosis, being a Kuwaiti citizen and have resided in Kuwait from birth to at least early adult life, a clear MS clinical course, at least 1 year has passed since initial diagnosis, and willingness to complete the study questionnaire. Exclusion criteria included: being a non-Kuwaiti, being <18 years of age, and having severe disability that prohibits questionnaire completion. In total, 135 Kuwaiti MS patients were approached for participation of which 128 returned the study questionnaire, whereas 211 Kuwaiti healthy controls completed the study questionnaire.

Study questionnaire

The study questionnaire was designed to collect demographic data and dietary habits of individuals in their childhood (≤10 years of age) and adolescence (11–17 years of age). The questionnaire was face validated by our collaborating MS consultant and a nutritionist. Then to validate the questionnaire scale adherence, we tested it on a sample of 10 individuals with an average response time of 5 minutes. Based on preliminary responses, questionnaire validity testing was conducted and responses showed adequate clarity and proper factor loading for dietary scale questions using principal component analysis. Demographic factors assayed included education, marital status, family history of nervous disorders, and type of nervous disorder. Dietary factors assayed included adolescence intake of daily fresh fruit and vegetable portions indicated as: 1) none, 2) one to two portions, 3) three to four portions, and 4) more than four portions. Adolescence fish consumption was assessed according to: 1) none/rare, 2) one to two times a month, and 3) once a week. Adolescence milk consumption as: 1) none/rare, 2) more than once a week, 3) once a day, and 4) more than once a day. Childhood and adolescence prepacked snacks were classified into: 1) none, 2)10% to 25%, 3) 25% to 50%, 4) 50% to 75%, and 5) >75% of daily nutrition. Childhood and adolescence fast-food consumptions were assessed as: 1) none, 2) one to three meals/week, 3) three to seven meals/week, and 4) most meals of the week. Lifestyle factors assayed included exercise in adolescence, exposure to passive smoking, use of nutritional supplements in adolescence, and presence of any food allergies, all of which were dichotomous yes and no questions.

Statistical analysis

Incomplete questionnaires from MS patients were included in data analysis where answers were given and excluded where answers were missing. Undefined or unknown responses were also excluded from analysis. Demographic variables were assessed by chi-square test and Fisher exact test when appropriate. Rank assignment of categorical variables was in an ascending order for all variables. Binary logistic regression was used to analyze categorical data to determine odds ratio (OR) with 95% confidence intervals (95% CI) for the analysis of environmental factors and MS risk. A two-tailed P-value < 0.05 was considered significant. Data was analyzed using IBM SPSS software version 28 (IBM, New York, NY).

   Results Top

Cohorts’ demographics are shown in [Table 1]. The sex ratio was biased toward more females in MS cohort as dictated by disease incidence being higher in females than males. MS patients had increased incidence of family history of a nervous disorder (OR: 3.05, 95% CI: 1.8–5.16, P < 0.001). The most common listed nervous disorders included MS (70.7%), epilepsy (12.2%), and Parkinson disease (7.3%). Whereas, in healthy controls, the most common listed neurological disorders were MS (36.1%), epilepsy (33.3%), and Alzheimer disease (5.6%), having a positive family history of MS associated with MS risk (OR: 4.27, 95% CI: 1.64–11.13, P = 0.003).
Table 1 Demographics of MS and healthy control cohorts

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Categorical results of the survey are shown in [Table 2]. We first analyzed the consumption of fresh fruits and vegetables during adolescence. In MS patients, 24.2% indicated rarely consuming fresh fruits and vegetables in comparison to 11.4% of healthy controls. Most MS patients (51.5%) and healthy controls (57.8%) stated their consumption was one to two pieces per day. While 18.8% MS patients and 20.8% healthy controls indicated eating three to four pieces daily. Only 5.5% of MS patients consumed more than four pieces per day, whereas 10% of healthy controls stated so. Daily consumption of more than four pieces of fruit and vegetables during adolescence was protective against MS risk (OR: 0.097, 95% CI: 0.03–0.314, P < 0.001). In addition, daily consumption of one to two pieces (OR: 0.28, 95% CI: 0.114–0.68, P = 0.006) and three to four pieces of fruit and vegetables showed gradual protection against MS risk (OR: 0.261, 95% CI: 0.098–0.696, P = 0.007). The incidence of food allergy was not different between the two cohorts (P = 0.8); however, its contribution to aversion of fruit and vegetable was noted since all listed food items in participants with allergy were fruits and vegetables. Reanalysis of daily fruit/vegetable consumption during adolescence excluding those with allergy remained significantly protective against MS (P = 0.047), specifically consuming more than four pieces daily (OR: 0.14, 95% CI: 0.038–0.516, P = 0.003). Fish and milk consumption during adolescence did not differ between cohorts (P P > 0.05). Neither did consumption of prepacked snacks in childhood (P = 0.466), or during adolescence (P = 0.078). Fast-food consumption during childhood significantly associated with MS risk in a gradual manner. Consuming one to three fast-food meals in a week (OR: 2.5, 95% CI: 1.48–4.24, P = 0.004), or four to seven fast-food meals per week (OR: 2.86, 95% CI: 1.23–6.62, P = 0.014), or most meals of the week (OR: 5.86, 95% CI: 1.96–17.5, P = 0.002) associated with MS risk. Similarly, fast-food consumption per week during adolescence when consuming one to three fast-food meals in a week (OR: 2.5, 95% CI: 1.39–4.63, P = 0.002), or four to seven fast-food meals per week (OR: 4.73, 95% CI: 2.19–10.22, P < 0.001), or most meals of the week (OR: 5.56, 95% CI: 2.03–15.19, P < 0.001) associated strongly with MS risk. Supplement use in adolescence and incidence of passive smoking during adolescence was not different between the two cohorts (P > 0.05). Physical activity during adolescence did not differ between the two cohorts (P = 0.25). A multinomial logistic regression analysis using factors found associated in this study as a set of predictive variables was found to accurately classify 71% of our sampled population into MS cases and healthy controls.
Table 2 Quantitative analysis of variables assessed in the study questionnaire

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   Discussion Top

The growing burden of MS in Kuwait cannot be fully explained by the current reported genetic associations with MS risk.[16],[17] While many studies support the association of viral infections, vitamin D deficiency, and smoking with MS risk we found none in our MS population so far.[18],[19],[20] We identified two dietary risk factors for MS in the presumed presence of a susceptible genetic background. The high incidence of MS positive family history in MS patients reported here suggests an isolated genetic background, increasing the rate of MS incidence, possibly confounded by consanguinity which is prevalent in the region; and is influenced by a recently introduced environmental factor.

Several reports have shown the association of nutrient deficient diet, referred to as “Western diet,” with inflammatory autoimmune diseases.[21],[22] We assessed dietary habits of MS patients during childhood and adolescence and results show an association of poor dietary habits with MS risk. Preadult diets deficient in fresh fruits and vegetables consumption and increased fast-food consumption associated significantly with MS incidence in later years. Healthy food items are critical sources of fiber, minerals, vitamins, antioxidants, and omega fatty acids, which collectively support a healthy immune system and reduce inflammation. Whereas diets high in processed foods that are rich in animal proteins and fats, and trans fatty acids are poor in nutritional value and increase MS risk and MS clinical course progression dramatically.[9],[23] Currently, there is mounting evidence supporting a healthy balanced diet for reducing MS risk and abating clinical progression.[24],[25],[26] Moreover, a recent study showed low fiber intake, low alpha-linolenic acid, and high intake of animal proteins to associate with the first MS demyelinating event.[27] Dietary factors modulate the immune response by affecting the cellular components of the immune system, the gut microbiota, and consequently the gut–brain axis. Plant-based nutrients consumption to attenuate and resolve MS symptoms has been shown to be effective in conjunction with MS disease modifying therapeutics.[28] Many fruit and vegetable derived compounds have been shown to diminish or resolve MS pathology in MS experimental animal models.[29] Human clinical studies have also corroborated the beneficial impact of fresh fruit and vegetables consumption in managing MS symptoms and reducing MS relapse.[30],[31] These findings, along with our findings here, suggest a need to consider nutritional interventions in tandem with MS therapeutics in managing MS disease.[32] The major limitation in our study is biased recollection and individual perceptions which cannot be avoided in survey-based studies.

   Conclusions Top

In Kuwait, the MS population has increased rapidly in the past two decades in conjunction with changes in lifestyle and dietary habits. Our previous studies show that common environmental factors associated with MS risk including vitamin D deficiency, smoking, and viral infections are not associated with MS risk in Kuwait. However, in this study, we showed that poor dietary habits inclusive of reduced intake of fresh fruits and vegetables and increased intake of processed foods during formative years is strongly associated with MS risk in Kuwait.

Financial support and sponsorship

This work was supported by Kuwait University research sector grant number MG04/15.

Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2]


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