Feasibility RCT of cocoa for fatigue in MS (2019) Coe et al

J

JohnTheJack

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Staff member
Drink cocoa for chronic fatigue.
Not a recommendation.
Not looked at details.

https://jnnp.bmj.com/content/early/2019/01/31/jnnp-2018-319496

Results 40 people with multiple sclerosis (10 men, 30 women, age 44±10 years) were randomised and allocated to high (n=19) or low (n=21) flavonoid groups and included in analysis. Missing data were <20% and adherence to intervention of allocated individuals was >75%. There was a small effect on fatigue (Neuro-QoL: effect size (ES) 0.04, 95% CI −0.40 to 0.48) and a moderate effect on fatigability (6 min walk test: ES 0.45, 95% CI −0.18 to 1.07). There were seven adverse events (four control, three intervention), only one of which was possibly related and it was resolved.

Conclusion A flavonoid beverage demonstrates the potential to improve fatigue and fatigability in RRMS.
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This is my comment on MS Society who are really casually promoting this without providing analysis.

There’s several newspapers covering this with more detail if people want to see further behind the claims:


I find it confusing because the daily mail says this;


“The new study, published in the BMJ Journal of Neurology Neurosurgery and Psychiatry, split 40 people recently diagnosed with the relapsing remitting form of MS and fatigue into two groups.


The first were told to drink a cup of either high-flavonoid cocoa powder mixed with heated rice milk every day for six weeks, or a low-flavonoid version for the same duration.


Participants were told to wait 30 minutes before taking any prescribed medication or eating or drinking anything else, but otherwise they could stick to their usual diet.


Fatigue levels were assessed throughout the study, and those on the drinks rated their fatigue on a scale of one to 10, at 10am, 3pm and 8pm every day.


Activity levels were also measured with a pedometer.


After six weeks, there was a small improvement in fatigue in 11 of those drinking the high-flavonoid cocoa compared with eight of those drinking the low-flavonoid version, researchers found.


Those drinking the high-flavonoid cocoa were also able to walk further than those in the other group during a six-minute walking test.


Pain levels also seemed to be lower in those on the high-flavonoid drink.”


Whilst medical news today said this


“A safe and easy way to relieve MS symptoms

The study found that drinking the high-flavonoid cocoa beverage had a "small effect on fatigue" and a "moderate effect on fatigability."


Specifically, those who drank the high-flavonoid version experienced a 45-percent improvement in fatigue and an 80-percent increase in walking speed.


Participants in the high-flavonoid group also reported feeling less pain, although the researchers did not objectively measure this symptom. Coe and colleagues conclude, "A flavonoid beverage demonstrates the potential to improve fatigue and fatigability in [relapsing-remitting MS].”


So it seems that in people with fatigue, I don’t understand the scale used, in this small trial of 40 people 11 people reported “help” with fatigue on high flavanoid cocoa versus 8 people on low flavonoid cocoa, I’m not sure if that suggests it was a bit more helpful over the placebo effect. Then there’s the boost in walking speed reported versus the other group . I couldn’t understand the original paper which can be read as well. It said something about not clinically significant but I didn’t understand what wasn’t.


I’m not sure the study warrants the hype and is seems potentially trivialising of this burdensome symptom (affecting us as well as MS) . It is obviously worth a try by anyone just going and drinking cocoa but I couldn’t see any reference to the specific cocoa products used although raw cocoa was mentioned in one article which is different to normal cocoa.


This is based on CFS fatigue research and dark chocolate and afaik NO ONE in the CFS community uses this as successful fatigue intervention (do they?)
 
AFAIK the health benefits of dark chocolate, all the way upto raw cocoa, are largely based on one flavonol, which is apparently helpful in repairing/maintaining the linings of blood vessels, although I may have missed a lot because that was the thing I was looking something to help with.

A more flexible and reactive vascular system may require less 'work' to get to respond appropriately, and possibly less fatigue/fatigability.

Given that, as far as anyone knows, ME has sod all to do with a stiff and unreactive vascular system, children get it so it seems an unlikely cause, I can see that it might help, a little, possibly, with fatigue, but as for addressing anything to do with ME?

I can't see that happening.

(of course I know very little about this, I'm just going off my own googling, which wasn't aimed at fatigue or ME, at all, and making, inferring, generalisations from that)
 
I don’t understand how the outcomes reported warrants the hype in the press of a feasibility study. This for example

https://www.scimex.org/newsfeed/chocolate-could-reduce-fatigue-in-people-with-ms

A nice cup of hot chocolate could be a safe, easy way to reduce fatigue symptoms associated with inflammation in people with multiple sclerosis (MS),
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Previous research suggests that dark chocolate, containing between 70 and 85 per cent cocoa solids, is associated with an improvement in subjectively assessed fatigue in people with chronic fatigue syndrome (ME).
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After six weeks there was a small improvement in fatigue in 11 of those drinking high flavonoid cocoa compared with eight of those drinking the low flavonoid version.
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High or pure cocoa drinks do not taste 'nice'. They are very bitter, which is why there is so much sugar in commercial hot chocolate. The commercial ones tend to have very little of the active compounds in, this tends to be stripped out in one of the processes used, the primary purpose of which is to reduce the bitterness.

Equating a high flavanol drink with a standard cup of hot chocolate isn't misleading, it's lying.

...and yes, it would seem the effect is marginal, at best. My limited understanding of what may be happening is that it's a very long term process, if anything real is happening, that any perceived benefits after drinking a 'nice mug of hot chocolate' are likely to be psychological/placebo.
 
So I've been drinking raw cacao powder/milk/hot chocolates for a decade now and feel it might improve blood flow/circulation, it just feels that way though. It's a good source of magnesium so that could have a calming effect too.

“cocoa flavanols help maintain endothelium-dependent vasodilation, which contributes to normal blood flow”
 
roller* said:
the recipe

https://jnnp.bmj.com/content/jnnp/e...DC2/embed/inline-supplementary-material-2.pdf

Cocoa powder / Rice milk / Sugar / Caffeine / Theobromine
same with both groups, only the cocoa powder had a different composition
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I just made that up with the following trivial modifications ;)

I have no theobromine
I have no alpro rice milk, so used semi skimmed cows milk
I have no sugar (I'm diabetic) so used a xylitol substitute
I used half a teaspoon of instant coffee, I have no idea what the amount of caffeine in that would be

Mixed together, nuked for a minute, mixed/stirred again, and nuked for another minute.

It's bitter, not as bitter as I expected but definitely an acquired taste. People may drink it for the 'health benefits' but I can't see anyone drinking it for pleasure.

Maybe theobromine tastes sweet, I've no idea what it's purpose is.

ETA - looked it up, it's bitter, I'm not sure why it's there as it comes from cocoa, seems to have the same properties as cocoa, why not just use more cocoa? It's clearly not the active part of the drink as the amount is the same for both drinks.

...and apparently making hot chocolate in a jug in a microwave isn't the best way to make it, sort of bitter hot chocolate with slimy lumps of 'chocolate' in the bottom of the cup - not like you would get from a poorly mixed hot chocolate powder. What can I say, it was fast, it works with coffee, soup, baked beans, porridge, who could have known that it wouldn't work with this. LOL

Science is a way of determining what doesn't work, right?

ETA 2 - okay, I googled it a bit more, I now suspect I know why the theobromine was added, to make sure both drinks had a physiologically active amount of theobromine. The low flavonol version may, just may, have had insufficient to be physiologically active and not had the same effect on things like blood pressure without it being added. Dunno, the caffeine is supposed to block that effect, but there must be a reason for including it.

People considering this should be aware that the high flavanol version will contain compounds that will drop blood pressure, unless caffeine is added, apparently. So those pwME with low BP should probably be careful. There is also definitely a stimulant effect, at least for me, far more than with coffee.

erm...I just looked up how much caffeine is in a tsp of instant coffee - 40mg ish in nescafe, so I used about a third of what this recipe calls for.
 
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