Abstract
Context: To counteract cumulative weight gain, a female veteran with multiple sclerosis with spinal cord involvement initiated a program of time restricted eating (TRE), eating all calories within a daily 6-hour window.
Findings: The patient experienced significant weight loss and improved cardiometabolic markers.
Conclusion/Clinical Relevance: Additional research is warranted to study TRE to mitigate obesity.
Keywords: Multiple sclerosis, Obesity, Weight loss, Intermittent fasting, Time restricted eating
Case description
A 56 year old female veteran with relapsing-remitting multiple sclerosis (MS), diagnosed in 2007, underwent neurologic surveillance imaging in early 2022. The patient had stable spastic tetraparesis, with an Expanded Disability Status Scale (EDSS) score of 6.0. She was independent with activities of daily living; she required intermittent assistance to walk about 100 meters. She was not on disease modifying therapy.
The patient had significant cardiometabolic risk factors: she was prediabetic (HbA1c 5.9) and overweight (BMI 29.2, height 160 cm, weight 74.8 kg, measured in June 2021).
The patient’s surveillance imaging revealed several new, non-enhancing lesions in the brain and spinal cord (right cerebral white matter, C4-C5 and C5-C6 levels, and T9-T10 level). To mitigate anxiety related to these findings, the patient reported increased eating, leading to gradual and cumulative weight gain. Per self-report, her weight increased from 68 to 72.5 kg (consistent with her June 2021 weight).
Determined to reverse the weight gain, the patient investigated weight management options via the Internet. She explored various dietary options, though remained noncommittal to a specific dietary regimen. After reading about time restricted eating (TRE), she concluded: “I could do that. It’s not restricting what you’re eating.” The patient self-initiated a TRE program entirely of her own volition.
TRE – a form of intermittent fasting – is a dietary strategy that has been shown to facilitate weight loss, improve cardiometabolic indices, and potentially reduce the risk of chronic metabolic diseases.1,2 TRE involves eating all calories within a designated, time restricted window. The patient’s program consisted of eating all calories in a 6-hour window (from 12–6 PM), and fasting outside that window. She strictly adhered to this program 7 days a week, and only reported “cheating” 1–2 times per month at social events outside the home. In 6 months, the patient experienced significant, progressive, and sustained weight loss (7.2 kg based on self-report, 9.5 kg from 1 year prior based on Veterans Affairs (VA) measurements). Her BMI approached normal (BMI 25.5, weight 65.3 kg), and her cardiometabolic markers improved as she went from prediabetic to normoglycemic. See Table 1 for details.
Table 1.
Cardiometabolic markers, pre – and post-time restricted eating initiation.
| Pre-TRE Initiation | Post-TRE Initiation | |||
|---|---|---|---|---|
| Date | 03/22/2021 | 06/10/2021 | 05/23/2022 | 06/22/2022 |
| Body Mass Index | – | 29.2 | – | 25.5 |
| Cholesterol | 197 | – | 177 | – |
| Triglycerides | 164 | – | 111 | – |
| LDL | 107 | – | 102 | – |
| HDL | 57 | – | 52 | – |
| HbA1c | 5.9 | – | 5.5 | – |
The veteran reported an improved motivation for reducing her sugar, soda, and carbohydrate intake with TRE, and found it easier to implement these changes. “If I’m only going to eat in a 6-hour window, I had better eat healthy,” she stated. She consumed fewer calories on the program without strict intention, calorie counting, or food journaling. Prior to TRE, she ate evening snacks and ate when “bored.” With TRE, she eliminated evening snacks and ate more conscientiously. She reported improved emotional, behavioral, and physical quality of life. She denied adverse events, weakness, or loss of function after TRE-initiation. VA annual examination confirmed stable function and EDSS score.
Discussion
MS is caused by chronic demyelinating inflammation cascades, which attack the central nervous system, including the spinal cord. Persons with MS and spinal cord injury (SCI) are at grave risk of weight gain and cardiometabolic dysfunction, directly contributing to high rates of obesity. Within the VA, over 50% of females and 60% of males with MS are overweight or obese.3
MS and obesity are each associated with significant systemic inflammation. There is some data to suggest that obesity in early life is associated with higher risk of MS development.4 Obesity may exacerbate underlying symptoms of MS, mediated by adipokines and central inflammation,4,5 and contribute to worse treatment response in children.6 There is a critical and pressing need to mitigate obesity in the MS and SCI populations.
Weight loss offers a myriad of benefits to mitigate the impact of obesity, but adherence to standard dieting is poor. Intermittent fasting has emerged as an alternative to standard dieting, and has been shown to be as effective for weight loss as standard dieting and daily calorie restriction.7
One of the most popular forms of intermittent fasting is TRE. TRE involves a simple time-based rule: all calories are consumed during a reduced time window, and only zero calorie drinks (e.g. water, unsweetened tea) are consumed outside that window. TRE helps activate and sustain the biological circadian rhythm at the molecular and cellular level, thereby improving glucose metabolism and reducing adiposity. In able-bodied populations, TRE also results in an unintentional reduction of 350–500 calories daily without calorie counting or food-intake monitoring.1 This appears consistent with the veteran’s experience: she eliminated evening snacks and unmindful eating, leading to unintentional caloric reduction.
TRE has been shown to be safe and effective in short-term clinical trials. TRE results in modest weight loss (1–4%), significant fat mass loss, and improved metabolic markers, including fasting insulin, insulin resistance, triglycerides, and oxidative stress.1,2 TRE may also offer unique biologic benefits to maintain weight loss. Calorie restriction alone often results in a weight loss plateau, followed by weight regain due to hormonal responses.8 In contrast, TRE may counteract weight regain through maintenance of lean muscle mass and alternating periods of fasting and feeding.9
Adherence to TRE is typically high, due to an unrestricted diet and lack of meticulous monitoring.9 The fact that this veteran self-initiated this program entirely of her own accord shows the perceived feasibility of the approach to this veteran. She denied challenges to implementation, and felt TRE fit well with her lifestyle and schedule of watching her grandchildren several days a week.
Conclusion
Improved weight loss strategies are greatly needed in the MS and SCI populations to counteract the continuing epidemic of obesity-related disease including cardiometabolic dysfunction. To our knowledge, this reports the first case of a self-initiated program of TRE resulting in significant and sustained weight loss in a patient with MS and SCI. No adverse effects were reported. Labwork demonstrated benefit in lipids and glycemic control since TRE initiation, consistent with TRE literature in able-bodied populations. The reported improvement in emotional, behavioral, and physical quality of life by the veteran is possible due to improvement in metabolic profile using this novel dietary intervention. The long-term efficacy and safety of time-restricted eating for weight loss are not clear.10 More research is warranted to study TRE in the MS and SCI populations to facilitate weight loss and improve cardiometabolic health and quality of life.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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