Hot cocoa for MS-related fatigue

While far more research is necessary, recent initial evidence points to diet-based, flavenoid-rich cocoa or dark chocolate having beneficial effects on the fatigue of people living with MS.

Multiple sclerosis (MS) is an inflammatory condition affecting the central nervous system. There are over 25,600 Australians living with MS, and on average more than 10 Australians are diagnosed each week. MS is more prevalent in women (75%), and diagnosis occurs mostly between 20–40 years of age.

The most common type (85%) is known as ‘relapsing remitting MS’, where people experience episodes of neurological dysfunction (days to weeks), with partial or complete recovery and clinical stability between attacks.

MS is thought to be an autoimmune disorder where the immune system attacks the myelin sheaths of the nerves, causing demylineation. Demyelination causes inflammation, scaring, and destruction of the axons; impacting upon the nerves’ ability to transmit electrical signals quickly and effectively.

There is no known cure for MS.

Immunomodulators are used to reduce the frequency of relapses and to try to slow the progression of disability, while acute relapses are managed with high dose corticosteroids.

As demyelination can occur in any part of the central nervous system, the symptoms of MS are unpredictable and vary between people, and from time to time in the same person.

Some symptoms are more specific to MS. For example acute painful loss of vision in one eye, or limb weakness and numbness that can occur with or without bladder/bowel dysfunction. Other symptoms are relatively non-specific e.g. spasticity, pain, fatigue.

These other symptoms related to MS may also require treatment.

An estimated 75–90% of people living with MS experience extreme tiredness and unusual fatigue. In some patients, chronic or relapsing fatigue may reflect disease activity, so improvement is noted with immunotherapy by reducing inflammation in the brain.

It is also important to rule out other causes such as hypothyroidism, anaemia; and manage contributing factors including nocturia, pain, restless legs syndrome.

The cause of MS-related fatigue and fatigability (inability to maintain both physical and cognitive performance) is complex, difficult to treat and negatively impacts upon quality of life in those living with it in a significant way.

While pharmacological approaches are not very effective, amantadine (increase dopamine release, NMDA antagonist) and modafinil (non-amphetamine psychostimulant) are sometimes used.

Similarly, exercise interventions appear to have the strongest evidence, but its success is also limited.

Therefore, other approaches and combination therapies are being investigated, including diet-based interventions. Chocolate makes everything better for some people – and in this instance, dark chocolate really might be the answer.

Dark chocolate containing 70–85% cocoa solids is high in antioxidants and flavonoids. Small studies have reported subjective improvement in people with chronic fatigue syndrome, while a pilot study in people with MS suggested improved sleep quality and reduced fatigue.

It is proposed that flavonoids helped by reducing inflammation and oxidative stress, and have also been noted to increase cerebral blood flow which may influence mood, cognitive performance, fatigue perception and the ability to perform specific movement tasks.

Recently, a small trial recruited 40 people living with MS to investigate the feasibility of conducting a larger trial and to gauge a potential effect size of flavonoid-rich cocoa on fatigue and fatigability. A parallel, randomized, double-blind placebo-controlled trial design was used for comparison only, with participants given low (1.02 mg/g) vs high (10.79 mg/g) flavonoid cocoa powder and instructions on making it into a hot chocolate beverage each morning.

After 6 weeks, a small effect on fatigue (Neuro-QoL: effect size 0.04, 95%CI –0.40 to 0.48) and a moderate effect on fatigability (6-minute walk test: effect size 0.45, 95% CI –0.18 to 1.07) were reported.

As this was an exploratory study, larger trials and much more research and evaluation are obviously required.

However, flavonoid-enriched hot cocoa, or dark chocolate for that matter, might be an easy, safe, and cost-effective way to improve quality of life for people living with MS.

Useful references

• Coe S, Cossington J, Collett J, et al. A randomised double-blind placebo-controlled feasibility trial of flavonoid-rich cocoa for fatigue in people with relapsing and remitting multiple sclerosis. J Neurol Neurosurg Psychiatry 2019;90(5):507– At: https://www.ncbi.nlm.nih.gov/pubmed/30833449
• Coe S, Axelsson E, Murphy V, et al. Flavonoid rich dark cocoa may improve fatigue in people with multiple sclerosis, yet has no effect on glycaemic response: an exploratory trial. Clin Nutr ESPEN 2017;21:20– At: https://www.ncbi.nlm.nih.gov/pubmed/30014865