Complementary Therapies in Medicine (2013) 21, 473—480

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

Immunomodulatory and therapeutic effects

of Hot-nature diet and co-supplemented
hemp seed, evening primrose oils
intervention in multiple sclerosis patients
Soheila Rezapour-Firouzi a,b,∗, Seyed Rafie Arefhosseini c,1,
Farhoudi Mehdi a, Ebrahimi-Mamaghani Mehrangiz b,
Behzad Baradaran d, Elyar Sadeghihokmabad a,
Somaiyeh Mostafaei a, Seyed Mohammad Bagher Fazljou e,
Mohammad-ali Torbati f, Sarvin Sanaie b, Fatemeh Zamani d
a
Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
b
School of Nutrition and Health, Tabriz University of Medical Sciences, Tabriz, Iran
c
Nutrition Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
d
Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
e
Center of Traditional Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
f
Food & Drug Organization, Tabriz University of Medical Sciences, Tabriz, Iran
Available online 25 July 2013

KEYWORDS Summary
Background: Multiple sclerosis (MS) is the most chronic and inflammatory disorder. Because of
Mizadj;
limited efficacy and adverse side effects, identifying novel therapeutic and protective agents
Multiple sclerosis;
is important. This study was aimed to assess the potential therapeutic effects of hemp seed
Hot-nature diet;
and evening primrose oils as well as Hot-nature dietary intervention on RRMS patients.
Evening primrose
Methods and materials: In this double blind, randomized trial, 100 MS patients with EDSS < 6
(Oenothera biennis
were allocated into 3 groups: ‘‘Group A’’ who received co-supplemented hemp seed and evening
L.);
primrose oils with advised Hot-nature diet, ‘‘Group B’’ who received olive oil, ‘‘Group C’’
Hemp seed (Cannabis
who received the co-supplemented oils. Mizadj, clinically EDSS and relapse rate as well as
sativa L.);
immunological factors (IL-4, IFN- and IL-17) were assessed at baseline and after 6 months.
Inflammation

∗ Corresponding author at: School of Nutrition and Health, Tabriz University of Medical Sciences, Tabriz, Iran. Tel.: +98 411 4421476;

fax: +98 411 4422438.

E-mail addresses: s.rfirozi@gmail.com, souheilarezapourfirouzi@yahoo.com (S. Rezapour-Firouzi), arefhosseinir@tbzmed.ac.ir
(S.R. Arefhosseini), Farhoudi m@yahoo.com (F. Mehdi), ebrahimimamagani@tbzmed.ac.ir (E.-M. Mehrangiz), Behzad im@yahoo.com
(B. Baradaran), aeass@yahoo.com (E. Sadeghihokmabad), somaiyehmostafaei@yahoo.com (S. Mostafaei), Dr.fazljou@yahoo.com
(S.M.B. Fazljou), drtorbati@yahoo.com (M.A. Torbati), sarvin.sanaie@gmail.com (S. Sanaie), fatemeh.zamanipour@yahoo.com (F. Zamani).
1 Tel.: +98 411 3357582.

0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.06.006
474 S. Rezapour-Firouzi et al.

Results: Mean follow-up was 180 ± 2.9 SD days (N = 65, 23 M and 42 F aged 34.25 ± 8.07 years with
disease duration 6.80 ± 4.33 years). There was no significant difference in studies parameters at
baseline. After 6 months, significant improvements in Mizadj, EDSS and relapse rate were found
in the groups A and C, while the group B showed a border significant decrease in relapse rate.
Immunological parameters showed improvement in groups A and C, whereas there was worsening
condition for group B after the intervention.
Conclusion: The co-supplemented hemp seed and evening primrose oils with Hot-nature diet
have beneficial effects in improving of clinical score in RRMS patients which were confirmed by
immunological findings.
© 2013 Elsevier Ltd. All rights reserved.

Introduction
Multiple sclerosis (MS) is a relatively common disease with
unknown etiology which results in neurological disability in
young adults. This condition affects over two million peo-
ple worldwide.1 Many of the current treatments are costly,
limited in efficacy, and possess unwanted side effects.2
Although the exact etiology of developing MS is dependent
on both genetic and environmental factors,3 pathological
events such as impairment of T helpers (Th) are involved.4
The major types of Th cells are Th1 cells that produce
interferon-gamma (IFN-), Th2 cells that produce inter-
leukin IL-45,6 and Th1/Th2 balance is considered one of the
risk factors in MS etiology. Also, Th17 (new T-cell subset)
produces IL-17 cytokine (a Key Player in MS pathogene-
sis) and cytokines derived from Th1 cells (IFN-) and Th2
cells (IL-4) are shown to repress the development of Th17
cells.7 Traditional Iranian Medicine (TIM) in Iran and many
other traditional medical theories (such as Traditional China
Medicine) have believed to exist of Cold and Hot natures in
peoples (Mizadj) and foods.8 The study of Shahabi et al., on
IL-4/IFN- ratio showed that the tendency of the Hot nature
people was to deviate toward Th2-like immune responses
to a greater extent than of the Cold-nature people.9 Thus,
the consumption of Hot-nature diet by persons suffering
from an autoimmune disease with a deviation toward Th1
immune responses (such as MS) might be useful, as Shahabi’s
results show that this diet may shift the immune system
toward Th2 responses. Approved treatment such as IFN-␤1a,
IFN-␤1b and many of available disease modifying therapies
Abbreviations: AA, arachidonic acid; ALA, alpha-linolenic acid;
CMF, cell membrane fluidity; CNS, central nervous system; D6D,
(FADS2)delta-6-desaturase; DGLA, dihomo-gamma-linolenic acid;
DHA, docosahexanoic acid (key omega-3); EDSS, Expanded Disabil-
ity Status Scale; EFAs, essential fatty acids; EPA, eicosapentaenoic
acid; EP, evening primrose; EPO, evening primrose oil; FAs, fatty
acids; FAME, fatty acid methyl esters; FDA, food and drug admin-
istration; FR, food records; GC, gas chromatography; GLA, gamma
linolenic acid; HS, hemp seed; HSO, hemp seed oil; IFN, interferon
(␤1b-␤1a-␤); IFN-, interferon-; IL, interleukin-4; LA, linoleic acid
(omega-6 family); LC-PUFA, long chain-polyunsaturated fatty acid;
MS, multiple sclerosis; MUFA, monounsaturated fatty acids; nqFFQ,
non-quantitative Food Frequency Questionnaires; NSRC, Neuro-
sciences Research Center; ␻3-PUFAs, omega-3polyunsaturated fatty
acids; PGE, prostaglandin (E1, E2, E3); PUFA, polyunsaturated fatty
acid; RBCs, red blood cells; RRMS, relapsing remitting multiple scle-
rosis; SFAs, saturated fatty acids; SDA, (STA) stearidonic acid; Th, T
helper (1-2); TIM, Traditional Iranian Medicine; USFA, unsaturated
fatty acid; W/C, Warmth/Coldness.
(DMTs) shifts the immune response from the Th1 to Th2
pattern by enhancing the production of anti-inflammatory
Th2 cytokines (ex. IL-4) and decreasing the production of
pro-inflammatory Th1 cytokines (ex. IFN-).10 As there is evi-
dence that omega-3-polyunsaturated fatty acids (␻3-PUFAs)
can suppress IFN-gamma production in MS patients,11 and
hemp seed oil (HSO) contains these substances as well as
evening primrose oil (EPO), the combination of these oils
as a dietary supplement has a potential to reduce pro-
inflammatory cytokines and targets this key mechanism of
disease and works like approved treatments.12,13 HSO has
been used as food/medicine in China for at least 3000 years14
may alleviate various chronic disease states.15 We therefore
designed a study to investigate the effects of a 9:1 combi-
nation HSO with EPO as a supplement to a Hot-nature diet in
comparison to the 9:1 combination of HSO with EPO without
a special diet and olive oil in the third group. HSO contains
over 80% in polyunsaturated fatty acids (PUFAs), with ␻3/␻6
ratio between 1:2 and 1:3, which is considered to be optimal
for human health,16 and it contains phytosterols, terpenes
and kinds of tocopherol that not only exhibits potent antiox-
idative properties for scavenging free radicals, but may also
acts on specific signaling pathways for regulating inflamma-
tory responses.17,18 EPO is being used in increasing amounts
in nutritional and pharmaceutical preparations, and may
alleviate various chronic disease states.15 Therefore, effects
of intervention appear to possess immune-modulatory and
anti-inflammatory roles; and may represent novel therapeu-
tic strategies against MS.
Materials and methods
This double-blind, randomized clinical trial was carried out
on 100 MS patients to determine the therapeutic and pro-
tective effects of Hot-nature diet and the co-supplemented
oils. MS patients were contacted and recruited through
the MS Society of Tabriz. Patients with a definite diag-
nosis of MS using the Kurtzke Extended disability status
score (EDSS) < 6 criteria19 ; with relapsing-remitting type of
MS (RRMS); ages 14—55 years were enrolled. Patients with
secondary or primary progressive MS, pregnancy, cortico-
steroid treatment, patients suffered concomitantly from
another chronic disease such as rheumatic diseases, serious
heart diseases, malignant tumors, and other neurological
and inflammatory illnesses were excluded. Patients were
allowed to continue their routine medications [only Inter-
feron: Avonex one time/week] (Table 1). A written informed
consent was completed prior to the study for all patients.
The patients completed a 3-day food record in the first
Immunomodulatory and therapeutic effects
Table 1 Clinical and demographic characteristics of the study patients n = 65 (23 men, 42 women).
Variable Group A (N = 23)
Mean ± SD
Age (years) 34.2 ± 7.5
Average age at onset (years) 25.0 ± 7.5
Disease duration (years) 6.26 ± 3.9
Variable
Interferon intake (avonex: interferon ␤1a, one time/week)
Gender (M/F)
Group A: Co-supplemented hemp seed and evening primrose oils and advised Hot nature diet.
Group B: Olive oil.
Group C: Co-supplemented hemp seed and evening primrose oils.
week, a non-quantitative Food Frequency Questionnaires
(nqFFQ) to assess food and drinks consumed and dietary
habits. They were asked to maintain their usual level of
physical activity and not to consume any supplements dur-
ing the study. The patients were then randomly assigned to
receive three dietary interventions:
‘‘Group A’’: Those receiving the co-supplemented oils,
18—21 g/day (6—7 g, three times daily) with advised Hot
nature diet,
‘‘Group B’’: Those consuming olive oil 18—21 g/day (6—7 g,
three times daily),
‘‘Group C’’: Those receiving the co-supplemented oils,
18—21 g/day (6—7 g, three times daily) for 6 months.
To achieve this objective, group A was asked to con-
sume ‘‘Hot nature diet’’ with a wide choice of foods and
drinks items permitted during each dietary period and deliv-
ered at home for 6 months [Appendix A]. Groups B and C
were asked to consume their usual diet during the inter-
vention. ‘‘Hot nature diet’’ includes foods with Hot nature,
low intake of cholesterol, hydrogenated or trans fatty acids
and saturated fats (fried foods), consumption of olive or
grape seed oils as main oils in diet, eating plenty of fresh
fruit and vegetables with Hot nature, nuts and seeds with-
out additives, fish and seafood, unrefined carbohydrates,
drinking plenty of water (avoiding too much drink containing
artificial additives, sweeteners or other stimulants), cutting
down sugar and refined starch (i.e. non-whole meal bread,
cakes, pastries, biscuits, sweets and soft drinks), consump-
tion of dairy products with honey or date and removing foods
with Cold nature [Appendix B], avoid of alcohol and smok-
ing. The patients were contacted monthly by telephone to
assess compliance. After baseline assessments, 100 patients
randomized to three groups according to following diagram
(Fig. 1).
All measurements of outcome parameters were repeated
at the end of the intervention period with the same approach
by the same assessors. Researcher, patients and those
involved in the data collection and assessment (neurolo-
gists and nutritionists) as well as data analysis were blind
regarding the type of interventions.
475
Group B (N = 22) Group C (N = 20)
Mean ± SD Mean ± SD
35.9 ± 7.8 33.7 ± 7.8
30.3 ± 8.1 27.6 ± 6.4
7.55 ± 5.08 6.60 ± 4.0
Group A (N = 23) Group B (N = 22) Group C (N = 20)
N (%) N (%) N (%)
22 (95.7) 22 (100) 19 (95)
16/7 11/11 15/5
Measurement of the disability status of patients
A medical history to check clinical status (inc. EDSS and
Relapse rate) and medications used were assessed [Appendix
C]. The functional disability status (disease severity) of
each patient was measured by a trained clinician using the
Kurtzke EDSS.19 Relapse rate of the included patients before
and after this study were recorded. Scales for the total
Kurtzke EDSS are from 0 to 10, in which the 0 score indi-
cates no disability at all and 10 indicates death due to
MS. Patients’ Natures and Temperaments (Mizadj: degree
of Warmth/Coldness or degree of Th2/Th1 or degree of IL-
4/IFN-) was determined for all patients according to TIM
by using a standard questionnaire [Appendix D].9
Blood sample processing and analysis
Venous blood samples (10 ml) were collected from the
patients before and after treatment. Serum was separated
and aliquots were stored at −80 ◦ C. The cytokine assay for
IL-4, IFN- and IL-17 was performed using the enzyme-linked
immunosorbent assay (ELISA) with techniques commercially
available kits (U-CyTech., Netherlands). The absorbance
of each well was read at 450 nm. Cytokine values were
expressed as pg/ml.
Statistical analysis
The statistical analysis was performed using SPSS software
(ver 14.0; SPSS Inc., Chicago, IL). Data was expressed as
mean ± standard deviation (SD). Differences in clinical and
biochemical variables between pre- and post within each
intervention group with normal distribution were analyzed
using paired t-test. Statistical significance was defined as
p < 0.05.
Results
Clinical and immunological results in RRMS patients
One hundred (34 M and 66 F) patients were enrolled in this
study. Fig. 1 summarizes the patient attrition patterns in
476
100 Patients' screened
100 Randomized
Group A
N=34
Co-supplement & diet
7 no toleration 10 no toleration
4 not compliant 1 discontinued
because of active
disease
N=23
Figure 1 Flowchart of the study; 100 patients were randomized to three groups; group A: Co-supplemented hemp seed and
evening primrose oils and advised Hot nature diet; group B: Olive oil; group C: Co-supplemented hemp seed and evening primrose
oils.
the study. The dropout rate was 35 from 100 patients (11
in group A, 11 in group B, and 13 in group C). This study
was performed between October 2010 and October 2011.The
patients’ characteristics and demographics are shown in
(Table 1). The sample consisted of 23 males and 42 females
with a mean age of 34.25 ± 8.07 years and mean disease
duration of 6.80 ± 4.33 years. There was no statistically
significant difference in the mean age, gender, disease dura-
tion, interferon intake, and average age at onset between
the treatment and control groups.
Clinical and immunological results
The clinical results of the trial are summarized in (Table 2).
In groups A and C, the improvements were significant
regarding the Mizadj, the EDSS and the relapse rate, while
in group B, Mizadj did not change significantly, EDSS dete-
riorated and the relapse rate showed a minor improvement
that did not reach statistical significance.
Results showed to reduce relapses by one-eighth on aver-
age over a 6 month period, in comparison, the total number
of relapses suffered by group B patients was three, for the
groups A and C was once. This result means that the co-
supplemented oils with or without advised Hot-nature diet
used in our study have shown a therapeutic effect toward
MS.
These results (Table 2) means that the co-supplemented
oils with or without advised Hot-nature diet used in our
study might have a therapeutic effect toward MS. Result
of (Table 3) indicates to the effects of the interventions
on IL-4, IFN- and IL-17 over the study in all three groups.
There is a trend in the decrease of mean pro-inflammatory
cytokines IL-17 and IFN- were observed in group A while
anti-inflammatory cytokine IL-4 concentration increased sig-
nificantly after 6 months in groups A and C which indicate to
decrease inflammation in these case groups, IL-17 and IFN-
 in group B increased significantly and in turn, resulted in
significant changes in their concentration among the groups.
There were no serious adverse effects in any of the 65 MS
patients.
S. Rezapour-Firouzi et al.
Group B Group C
N=33 N=33
Olive oil Co-supplement
10 no toleration
3 not compliant
N=22 N=20
Discussion
Possible mechanisms
The theory of ‘‘Hot and Cold natures’’ founds its origin
from ancient Greece medicine by Hippocrates (Greek physi-
cian, 460—375 BC) and Galen (199—129 BC).20,21 Hippocrates
says let’s our diet be our medicine, and Avicenna said
that for each person there is specific foods for himself.
The most important rule of all the ancient theories was
the maintenance of the balance between the fundamental
body elements, among which Warmth and Coldness played a
completely essential role.8 Warmth/Coldness score (Mizadj:
degree of Warmth/Coldness or degree of Th2/Th1 or degree
of IL-4/IFN-) expresses itself over a spectrum with most
people somewhere between the extremes. We calculated a
Warmth/Coldness score using the data from the question-
naires for each patient (Appendix D). It is observed that
intermediate forms or combinations of two or more tem-
peraments, so most people are under influence of both the
Hot and the Cold elements22 and we could evaluate the
severity of each nature in a person by Warmth/Coldness
ratio (Appendix D). It means that in a person with a very
Hot nature, Warmth/Coldness ratio is high (such as allergic
patients with tendency to Th2-like responses) and in a per-
son with a very Cold nature, Warmth/Coldness ratio is low
(such as MS patients with tendency to Th1-like responses).
Therefore, an allergen can induce allergic reaction in Hot
nature persons with a higher than in cold nature persons,
because the former have a greater tendency to Th2-like
responses.23
Immune responses during infancy and early childhood are
dominated by Th2 cytokines, but the shifting toward Th2
pattern decreases with age,24 and an allergen can induce
allergic reaction in child with a higher strength than adults.
This is in agreement with TIM’s belief that the nature is
dominated by Warmth at birth but its Warmth decreases
with age.8 This critical point that we should indicate why
MS attacks is observed in the start of adulthood age. Sha-
habi et al., showed the persons of a Hot nature had more
Immunomodulatory and therapeutic effects 477

Table 2 Effect of intervention on mean (±SD) clinical variables: Mizadj (Warmth/Coldness ratio), extended disability status
score (EDSS) and relapse rate in trial groups of RRMS patients comparison to baseline.

Variables Group A (N = 23) Group B (N = 22) Group C (N = 20)

Baseline 6 months P Baseline 6 months P Baseline 6 months p*

Mizadj 1.05 ± .63 1.74 ± .88 0.001 .90 ± .47 .78 ± .43 0.116 1.01 ± .63 1.22 ± .8 0.017
EDSS 2.76 ± 1.39 1.77 ± 1.7 0.001 3.45 ± 1.41 1.41 ± 3.86 0.005 3.25 ± 1.94 1.83 ± 2.95 0.002
Relapse ratea .31 ± .21 .04 ± .2 0.001 .38 ± .49 .18 ± .39 0.053 .43 ± .40 .05 ± .22 0.002
Group A: Co-supplemented hemp seed and evening primrose oils and advised Hot nature diet.
Group B: Olive oil.
Group C: Co-supplemented hemp seed and evening primrose oils.
Mizadj: degree of Warmth/Coldness or degree of Th2/Th1 or degree of IL-4/IFN-␥.
a Baseline refereed to average of relapse rate per 6 month over 2 years.
* p for paired-t test.

deviation of the immune system toward Th2 responses than
the persons of a Cold nature, and in agreement with TIM
practitioners’ view that MS (Th1-mediated autoimmune dis-
ease), is more prevalent in Cold nature persons than in Hot
nature. Immunological assay confirmed the results of clin-
ical examinations, (Tables 2 and 3), indicated that A and
C groups and special A group have a higher rate of devia-
tion of the immune system toward Th2 responses and were
healthier in comparison with B group, while a hallmark in the
pathogenesis of MS is a shift in the ratio of Th cells toward
Th1 cells.25 The current studies suggest Th17 immunity plays
an important role in MS and blocking this cytokine protects
against disease.10 In spite of, anti-inflammatory effect was
seen in A and C groups, results showed a strong trend toward
a decrease in pro-inflammatory cytokines IL-17 and IFN-
was seen mainly in A group (Table 3), while increases in
IFN- and IL-17 were seen in B group. Results show that
intervention in A group with Hot nature substances blocks
the expression of IL-17 cytokine (Table 3). These results are
in agreement with the complications relating to Hot or Cold
nature dominance and targets this key mechanism of dis-
ease and works like approved treatments. It may explain why
therapies that promote a Th1 to Th2 cytokine-shift are ben-
eficial in MS patients. All approved therapies, besides many
of those under investigation appear to possess immunomod-
ulatory and anti-inflammatory roles as the main mechanism
of action that Beta-interferons and Glatiramer acetate are
on top of this list.12,13 This would mean less deviation toward
Th1 immune responses and may lead to a reduction in dis-
ease severity in the patients of the A group (Tables 2 and 3).
Based on TIM practitioners’ view that Hot nature foods is
useful for MS patients, while Cold nature foods aggravates
their disease, also women is dominated twice more than
men by Cold nature and this confirms autoimmune diseases
such as MS is mostly common in women more than men,
parameters like weather coldness, lack of sun light expo-
sure (it may explain why vitamin-D therapies that promote
a Th1 to Th2 cytokine-shift are beneficial in MS patients)
and stressful life enhance Coldness in subjects.26 Increase
of W/C ratio (Mizadj) agreeing with increase of EDSS and
relapse rate parameters were significantly better in A and C
groups compared to B group, and case groups felt physically
and emotionally healthier (Table 2). The major difference
detected in this trial was the greater reduction relapses rate
in groups A and C. A trend favoring in group A was maintained
on EDSS, relapse rate and functional score until the end of
the study for all measurements while, no therapy exists that
can confer prolonged remission in MS and therapeutic agents
are only partly effective. Their long-term beneficial effects
are uncertain with side effects.27
Agreeing with above changes, dietary PUFA (co-
supplemented oils) and their metabolites affect inflam-
matory functions and cytokines production during the 6
months, because ␻3-PUFAs, can suppress IFN- production

Table 3 Effect of intervention on mean (±SD) immunological factors: interleukin-4 (IL-4), interferon-y (IFN-␥) and interleukin-
17 (IL-17) in trial groups of RRMS patients; comparison to baseline.

Trial groups variables Group A (N = 23) Group B (N = 22) Group C (N = 20)

Baseline 6 months P Baseline 6 months P Baseline 6 months p*

IL-4 .56 ± .20 .70 ± .17 0.007 .50 ± .50 .41 ± .14 0.31 .81 ± .12 .96 ± .11 0.006
IFN-␥ .56 ± .04 .24 ± .04 0.001 .22 ± .06 .39 ± .06 0.005 .35 ± .23 .30 ± .14 0.079
IL-17 .51 ± .09 .39 ± .04 0.009 .26 ± .11 .41 ± .20 0.006 .51 ± .03 .45 ± .15 0.289
Cytokine values were expressed as pg/ml.
The absorbance of cytokins levels was read at 450 nm.
Group A: Co-supplemented hemp seed and evening primrose oils and advised Hot nature diet.
Group B: Olive oil.
Group C: Co-supplemented hemp seed and evening primrose oils.
* p for paired-t test.
478 S. Rezapour-Firouzi et al.

SUMMARY OF OMEGA SUMMARY OF OMEGA 3 SUMMARY OF OMEGA 6

9 PATHWAY: PATHWAY: PATHWAY:

Linolenic Acid/Omega 3 (LNA) Linoleic Acid/Omega 6 (LA)

18:0 Stearic acid
D6 Desaturase (D6D)
vitB6,Zn,Mg
D9Desaturase D6 Desaturase (D6D)

18:1 n-9 oleic acid Stearidonic Acid

Gamma Linolenic Acid (GLA)
D6Desaturase Elongase

Elongase
Eicosatetraenoic Acid
18:2 n-9
Dihomo-gamma-linolenic
D5Desaturase (D5D) Acid (DGLA)
Elongase VitC,B3,Zn Anti-inflam: PG Series I
Eicosapentaneoic Acid (EPA)
20:2 n-9 Lipoxygenase converts EPA to: D5Desaturase (D5D)
Anti-inflam: Leukotrienes

D5Desaturase Elongase
Arachidonic Acid (AA)
(COX 1) converts EPA to: (COX 2) converts AA to:
Anti-inflam PG Series 3 Pro-inflam PG Series II
20:3 n-9 Docosapentaenoic Acid

eicosatrienoic acid D4Desaturase

Docosahexaenoic Acid (DHA)

Figure 2 The polyunsaturated fatty acids biosynthetic pathway.

in MS patients,11 prior studies have demonstrated a rela-
tion between MS mortality and dietary fat,28 and lipids can
be found in two structural components; the neuronal mem-
brane (about 50%) and the myelin sheath (about 70%) and
a high proportion of lipid 85%.29 This results likely due to
remyelination that occurs during the early phases of disease;
whereas this is rare at more progressed stages.30 Current
estimates of the ␻3/␻6 PUFAs ratio in developed countries
are as low as 1:25 with recommendations to the public that
it should be much higher (ideally 1:4).31 The ␻6/␻3 ratio in
HSO is normally between 2:1 and 3:1, which is considered
optimal for human health.16 Horrobin showed that prelimi-
nary results the use of EPO and colchicine combined therapy
in MS patients suggest that may be of considerable value.32
EPO is being used in increasing amounts in nutritional and
pharmaceutical preparations, and there are claims that it
may alleviate various chronic disease states.15 The EPO
content of 9% GLA is the single most important parame-
ter that is metabolized into DGLA, the natural precursor
of PGE. ␤-Carotene is a pro-vitamin A and gives a charac-
teristic color to EPO.33 The HSO/EPO ratio in this study is
9:1, so ␻3/␻6 PUFAs ratio reach to 1:4 or higher, that is
competitive inhibition of the conversion of dihomo-gamma-
linolenic acid (DGLA) to arachidonic acid (AA) resulting in
more anti-inflammatory prostaglandin E1(PGE1). AA is a
precursor of pro-inflammatory and pro-aggregator (PGE2),
while gamma-linolenic acid (GLA) and DGLA are precursors
of anti-inflammatory PGE1 (Fig. 2). The presence of both
GLA and stearidonic acid (SDA) in HS and EP oils, typically
at a favorable ␻6/␻3 ratio of 2:1 allows this enzymatic step
with D6D to be efficiently bypassed.34 GLA and SDA are prod-
ucts of this enzyme delivering to the patient organism by the
co-supplemented oils in this trial. These mentioned basic
components for cellular metabolic pathways could easily
replace to this intervention in patients organism A and C
groups. It was found that a 9:1 HSO with EPO combina-
tion with and without Hot-nature diet led to a significant
reduction in the EDSS score and the relapse rate, and the
patients general health and well-being improved that may
be due to higher PUFA in peripheral and brain tissue, etc.
These results support the hypothesis of EFA abnormalities in
MS patients, and indicate that the problem could well be
one of conversion of EFA to LC-PUFA (according to: Fig. 2),
as originally suggested before. In addition, supplementation
with PUFAs may require additional vitamin E intake to pre-
vent increased peroxidation of membrane lipids,35 while
the total amount of HSO tocopherols (␣-, ␤-, ␥-tocopherol,
␦-tocopherol) is high between 80 and 110 mg/100 g, with ␥-
tocopherol as the main tocopherol (85%) that exhibit potent
antioxidative properties for scavenging free radicals.18 The
co-supplemented oils are foodstuffs and do not act as rapidly
as most medications, so any effects will take time to appear.
It means, most patients who respond to supplementation
usually report noticeable benefits within 1 or 2 months. The
minimum trial period should be at least 6 months, as stud-
ies have shown that it takes 10—12 weeks for PUFA levels
in brain cell membranes to return to normal levels after
a long-standing deficiency.29 Uncontrolled diet is the other
Immunomodulatory and therapeutic effects
important confounding factor. Based on studies the use of
co-supplemented oils (8:2 ratio is better, which is consid-
ered to be optimal for human health) either alone or in
conjunction of different immunomodulation therapy syn-
thetic drugs (which may have synergistic effects with each
other) for longer periods in MS patients. Hot-nature diet
and co-supplemented oils may prevent several inflamma-
tory diseases and neurodegenerative disorders, because the
changes in lipid biology identified in MS may be relevant to
other psychiatric and inflammatory conditions.
Conclusion
A 9:1 combination of HSO and EPO as a dietary supplement
in a daily dose of 18—21 g/day over a period of 6 months
showed immune-modulating effects in our study with RRMS
patients resulting in significant improvements of the EDSS
score and the relapse rate compared to a control group
receiving 18—21 g olive oil per day.
Small changes in the levels of the cytokines were
observed in all groups and were rather consistent with the
clinical outcomes: IL-4 increased significantly in group A and
C, IFN-␥ decreased significantly in group A and increased in
group B.
The Mizadj score increased in both active treatment
groups significantly. Further research must show the prop-
erties of this score and its the correlation with the clinical
data.
From the positive results of this study regarding the clini-
cal improvements, there is need for a trial conducted under
conditions which reduce the possible bias in our study due
to its open design; the most urgent issue would be an appli-
cation form for the vegetable oils which hides their origin
but keeps their properties.
Conflict of interest
There was not any conflict of interests to declare.
Acknowledgments
This work was supported by deputy of Tabriz University of
Medical Sciences for a part of the budget (25% of grants)
to run the project and authors personal budge (75% of
grants) for the preparation of the herbal oils. The study
was approved by the Neurosciences Research Center (NSRC)
and Local ethics committee of Tabriz University of Medical
Sciences.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.
1016/j.ctim.2013.06.006.
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