Postprandial Somnolence in Multiple Sclerosis T.Christmas1, N.Singh 2, S.Reyes2,3, K.Allen- Philbey2,3, G.Giovannoni 2,3

Background Results: Postprandial Somnolence (PPS), or “Food Coma” in lay terms, is described as  the drowsiness that follows a meal. Previous theories of cerebral Survey responses of n=77 pwMS (mean age 45.1 ± 11.5 years; 62.3% hypoperfusion due to redistribution of blood stream to the mesenteric female) and n=37 pw/MS (mean age 47.02 ± 13.9 years; 63.8% female) were vessels have been debunked, and this phenomenon is thought to be related gained.  to the activation of the parasympathetic nervous system in response to Of these, 64.5% of pwMS reported suffering from food coma compared to expansion of the stomach and duodenum from a meal, the release of 47.1% pw/MS.  hormones such as cholecystokinin in response to eating and the effect of No correlation was noted between EDSS and SSS. 4,5 neuropeptides or satiety signals on sleep centres directly . Characteristics Number pwMS pw/MS It has been observed in clinical practice that people with multiple sclerosis Gender Female 48 (62.3%) 23 (63.8%) (pwMS) seem to be more to susceptible to PPS. A recent online survey by Male 29 (37.7%) 14 (36.2%) the Barts MS Blog found that the 84.9% of pwMS reported suffering from Age Mean, SD (range) 45.1 ± 11.5 (23 - 71) 47.02 ± 13.9 (16 - 73) PPS4. This finding clearly identifies a need for further research within the Subjective Yes 50 (64.5%) 17 (47.1%)

field. reporting of food No 27 (35.5%) 20 (52.9%) coma SSS Mean, SD (range), mode 3.46 ± 1.67 (1 – 6), 3 2.52 ± 1.18 (1 – 6), 2 EDSS Mean, SD (range), mode 4 ± 1.9 (1.5 - 7.5), 2 N/A Aims of the Project Table 2: Cohort characteristics (1) To compare whether pwMS suffer from PPS more than people without MS (pw/MS) (2) To examine whether the severity of PPS is correlated to the severity of MS The mean SSS for pwMS (3) To obtain information on the treatments patients are using and how was 3.46, whilst the mean SSS effective these treatments have been for pw/MS was 2.52 (p=0.001). pwMS The mean SSS for pwMS who pw/MS didn’t describe having fatigue as a symptom was 2.80. Methodology Qualitative research was conducted using an online survey, emailed to 350 1 2 3 4 5 6 pwMS. These patients were from the Barts MS Database and had previously Graph 1: Frequency of Stanford Sleepiness Score consented to being contacted for research purposes. Their siblings, partners and friends were also asked to complete a similar survey for the general From the pwMS, 18% felt their PPS started after anything they ate, 61% population to allow comparison between the two groups. Participants were after an average meal, 22.4% after a slightly large meal and 18.2% after a asked to complete the survey one hour after eating lunch. very large meal. From the pw/MS, 12.5% started after eating anything, 12.5% after an Both surveys measured: average sized meal, 50% after a slightly large meal and 25% after a very  Demographics (age, gender and ethnic origin) large meal.  Co-morbidities and regular medications 70

 Contents, size, type and completion of meal 60

 Time elapsed between meal and completion of study, onset of symptoms 50

and duration of symptoms 40 pwMS  Subjective reporting of suffering from food coma 30 pw/MS  Sleepiness using the Stanford Sleepiness Score (SSS) 20  Intervention, type and effect of intervention 10

0 Scale Rating Degree of sleepiness Eating Average sized Slightly large Very large 1 Feeling active, vital alert or wide awake anything meal meal meal 2 Functioning at high levels, but not at peak; able to concentrate Graph 2: Differences between the 2 groups in comparison to meal size 3 Awake, but relaxed; responsive but not fully alert 4 Somewhat foggy, let down 63% of pwMS reported making changes to their diet to help their 5 Foggy; losing interest in remaining awake; slowed down symptoms: these included reducing the portion size, the number of portions 6 Sleepy, woozy, fighting sleep; prefer to lie down eaten in a day and reducing the amount of specific food components 7 No longer fighting sleep, sleep onset soon; having dream-like thoughts consumed: specifically carbohydrates and fat. Exercise Table 1: The Stanford Sleepiness Scale Caffeine and exercise were 12% also commonly used, with 20% and 13% of pwMS Reduce portion reporting having tried these as size Discussion 22% solutions to improve Caffeine intake Reduce number of  pwMS are affected by PPS more than pw/MS - more people with MS their symptoms of PPS. 25% subjectively felt that they suffered from the phenomenon than the general meals eaten 13% population, but this has also been demonstrated objectively using the SSS. Graph 3: Interventions in pwMS Reduce  It is well established that pwMS suffer from fatigue more than the general group by method and percentage Reduce fat carbohydrate population, but it is clinically useful to determine whether PPS is a major consumption consumption factor during their daily routines as tailored advice could be given to help 15% 13% with this.  pwMS are adopting self-management strategies to help reduce their symptoms of PPS, the most commonly used intervention was caffeine, References however patients are making changes to their diet to improve their 1. FY1, Northwick Park Hospital symptoms which has had varying effects on their symptoms. 2. Deparment of Neurosciences, The Royal London Hospital, Barts Health NHS Trust  Moving forward it could be useful to examine the effect of specific food 3. Blizard Institute (Neuroscience), Barts and The London School of Medicine & Dentistry, QMUL 4. Giovanonni, Gavin. “Food Coma: Does it Affect you?”, Barts MS Blog, 14/01/19, groups on PPS symptoms; larger sample sizes and an improved response 5. Bazar KA, Yun AJ, Lee PY. Debunking a myth: neurohormonal and vagal modulation of sleep centers, not rate would be required to make the project more robust. redistribution of blood flow, may account for postprandial somnolence. Med Hypotheses 2004;63:778e82.