CHAPTER 19 | Nutrition Management of Neurological Disorders 291


individual’s functional status per the ALS Functional Rating Scale (ALSFRS-6) and the Harris-Benedict equation, the estimated daily energy expenditure can be determined using the ALS Nutrition Calculator.75,76 In many cases, offering three meals and three snacks daily may enhance energy intake. If individuals later receive artificial ventilation with enteral nutrition, their resting energy expenditure may be lower.77 Additional energy, protein, and vitamins may be needed to maintain nutritional status and prevent weight loss and malnutrition. Foods high in carot- enoids, omega-3 fatty acids, and vitamin E may help prevent or delay onset.78


Diet and feedings should


provide antioxidants (eg, selenium and vitamins E and C) and zinc, magnesium, potassium, folate, omega-3 fatty acids, lycopene, and phosphorus. Those diag- nosed with ALS should avoid excess iron- and copper- containing foods.43


Energy and protein can be provided


in the form of additional portions, fortified foods, or oral nutrition supplements, which may help coun- teract wasting. Because there is low risk and low cost associated with these interventions, early and aggres- sive nutrition support should be offered. For individuals with ALS, constipation can be


a concern. Constipation is attributable to a variety of factors, but it often results from diminished dia- phragm function and decreased activity levels. A diet without adequate fluid and fiber may exacerbate the problem. The nutrition practitioner should review and encourage adequate fiber, food, and fluid intakes and consider a fiber supplement if indicated. Exercise may also aid in preventing constipation.79 When swallowing becomes severely impaired,


enteral nutrition may be considered for persons with ALS. Fatigue associated with eating and drinking, limb weakness that impairs the ability to self-feed, loss of appetite, and avoidance behaviors associated with mealtimes may result in inadequate oral intakes.80 Because of the high incidence of dysphagia, especially with bulbar ALS, individuals may not be able to con- sume any food or medications orally. In addition, due to the hypermetabolic state seen in some, the person may continue to eat orally but benefit from additional energy provided by a tube feeding. Because ALS gen- erally progresses quickly, it is important for the health care team to discuss artificial feeding and hydration early in the disease process. Standard polymeric


Multiple Sclerosis


In MS, the immune system attacks the myelin sheath that covers the nerves. As a result, communica- tion between the brain and the rest of the body is impaired. Nerve damage can be permanent. Although there is no cure for MS, medications are available to hasten recovery from attacks and help manage symp- toms. Some individuals may experience long periods of remission without any new symptoms.82


Prevalence and Risk Factors


The prevalence of MS varies by location and increases as the distance from the equator increases. Why this occurs is unclear but could be related to sun exposure, genetic factors, or both.83


Individuals exposed to high


amounts of ultraviolet radiation seem to have a lower risk of MS, whereas people living in colder climates and those with low sun exposure and deficient vita- min D levels have higher risk. MS is generally diag- nosed between ages 20 and 40 years. Great strides have slowed disease progression, although the life expectancy for individuals with MS is approximately 7 years less compared with healthy individuals. Other risk factors for MS include genetics, certain


infections, smoking, obesity, environmental factors, certain autoimmune diseases, age, sex, and race.


enteral formulas are routinely used, providing 25 to 30 kcal/kg and 0.8 to 1.2 g protein per kilogram of body weight per day. Parenteral nutrition is not rou- tinely indicated.43


Consider the wishes of individuals


with ALS and refer to their advance directive, includ- ing the right to refuse treatments.


Prevention of Amyotrophic Lateral Sclerosis


There are no definitive means to prevent ALS. People with ALS can participate in clinical trials that help researchers learn about potential causes and risk factors to reduce disease incidence. In addition, ALS multidisciplinary clinics specialize in helping to improve the quality and length of life of people living with ALS.81


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