Plain English Summary
Background and study aims
Multiple sclerosis (MS) is one of the most common diseases of the central nervous system (brain and spinal cord). Healthy nerves are coated in a fatty casing (myelin sheath) which helps messages to travel quickly and smoothly along nerves. When a person is suffering from MS, the immune system, which normally helps to protect against infection, attacks the myelin sheath, stripping it from the nerves (demyelination). This demyelination means that messages cannot travel along the nerves effectively, causing a range of symptoms including problems with balance and coordination and weakness in the arms or legs. One of the most common symptoms of MS is fatigue (extreme tiredness), affecting around 80% of sufferers. Pure cocoa may have the ability to improve fatigue because it contains substances called flavonoids. Flavanoids are becoming increasingly recognized for their potential to improve bodily processes which can worsen fatigue due to its antioxidant properties. However to date, no well-designed studies have looked at the role of cocoa consumption for fatigue management in people with MS. The aim of this study is to find out whether a flavonoid-rich cocoa drink is an effective means of improving fatigue in people with MS.
Who can participate?
Adults diagnosed with relapsing-remitting MS (RRMS) within the last 5 years who are experiencing fatigue
What does the study involve?
Participants are randomly allocated to one of two groups. Those in the first group are asked to drink a hot flavonoid-rich pure cocoa drink every morning for six weeks. Those in the second group are asked to drink a hot low flavonoid pure cocoa drink every morning for six weeks. At the start of the study and again after three and six weeks, participants in both groups completes a number of questionnaires and physical assessments in order to find out if their fatigue has improved. Participants also provide a blood sample at these times so that the level of glutathione (a chemical indicator of antioxidant status) can be measured.
What are the possible benefits and risks of participating?
It is currently unknown whether there will be any direct benefits to those taking part in the study. There is a small risk of pain or bruising during and after blood testing.
Where is the study run from?
1. Oxford Brookes University (UK)
2. John Radcliffe Hospital, Oxford (UK)
When is the study starting and how long is it expected to run for?
January 2016 to December 2017
Who is funding the study?
Multiple Sclerosis Society (UK)
Who is the main contact?
Dr Shelly Coe
A feasibility study to determine whether the daily consumption of flavonoid-rich pure cocoa has the potential to reduce fatigue in people with Relapsing and Remitting Multiple Sclerosis (RRMS)
The aim of this study is to explore the potention of a flavonoid-rich cocoa drink in the treatment of fatigue in people with Multiple Sclerosis (pwMS).
West Midlands - Solihull Research Ethics Committee, 31/03/2016, ref: 16/WM/0134
Randomised; Interventional; Design type: Treatment, Dietary, Physical
Primary study design
Secondary study design
Randomised controlled trial
Patient information sheet
Not available in web format, please use the contact details to request a patient information sheet
Specialty: Neurological disorders, Primary sub-specialty: Multiple sclerosis; UKCRC code/ Disease: Neurological/ Systemic atrophies primarily affecting the central nervous system
Following provision of informed consent and study screening, eligible participants complete a baseline assessment and are randomly allocated to either the high flavonoid cocoa intervention group or the control cocoa group.
High flavonoid cocoa intervention group: Participants will consume a high flavonoid pure hot cocoa drink daily (in the morning) for 6 weeks (in a normal sized mug).
Control cocoa group: Participants will consume a low flavonoid hot cocoa drink daily (in the morning) for 6 weeks (in a normal sized mug).
Participants in both groups repeat the baseline assessments at three and six weeks. Also during the six weeks, participants will be asked to wear a wrist watch for 2-3 of the 6 weeks, in order to gather information about daily activity. Three times a day participants will receive a text message asking about level of fatigue via a mobile phone.
Primary outcome measure
1. Fatigue is measured using a numerical rating scale (NRS) at baseline and three times daily for six weeks
2. Fatigability is measured using a 6 minute walk test and The Adult Memory and Information Processing Battery (AMIBP) at baseline, 3 and 6 weeks
Secondary outcome measures
1. Compliance to the intervention is determined through measuring blood glutathione levels at baseline, 3 and 6 weeks
2. Levels of physical activity are measured using wearable activity monitors (worn like a watch) for a total of 17 days (3 days prior to trial, week 3 and week 6) and The Physical Activity Scale for the Elderly (PASE) questionnaire at baseline, 3 and 6 weeks
3. Dietary patterns are measured using a 3-day 24-hour food record at baseline, 3 and 6 weeks
4. Inflammation is measured by testing blood TNF-alpha and lipid peroxidation levels at baseline, 3 and 6 weeks
5. Quality of life is measured using EQ5D5L at baseline, 3 and 6 weeks
6. Health related quality of life specific to MS is measured using the Preference-Based Multiple Sclerosis Index (PBMSI) at baseline, 3 and 6 weeks
7. Demographics and basic health information are measured using the basic health questionnaire at baseline, 3 and 6 weeks
8. Limitations in daily activity is measured using the Barthels Index (BI) at baseline, 3 and 6 weeks
9. Anxiety and Depression are measured using the Hospital Anxiety and Depression Scale (HADS) at baseline, 3 and 6 weeks
Overall trial start date
Overall trial end date
Reason abandoned (if study stopped)
Participant inclusion criteria
1. Aged 18 years and over
2. New (<10 year) clinical diagnosis of relapsing-remitting multiple sclerosis (RRMS)
3. Treatment naïve or taking first line DMTs - glatiramer acetate, interferone beta, teriflunomide and
4. Willing to comply to consuming the cocoa drink;
5. A fatigue measure of greater than 4 on the Fatigue Severity Scale (FSS)
6. An Expanded Disability Status Scale (EDSS) score of < 4.5;
7. Able to walk with or without a walker for at least 16 meters (length of the 6 minute walk test);
Target number of participants
Planned Sample Size: 40; UK Sample Size: 40
Participant exclusion criteria
1. Those experiencing a relapse or sudden change in their MS symptoms within the previous three months
2. Conditions affecting the central nervous system other than MS (excluding migraines)
3. Contraindications to providing a blood sample
4. Any other conditions that may be associated with fatigue, e.g. anaemia
5. On medication for the treatment of depression
6. Pregnant or lactating
7. Insufficient mental capacity to consent
8. Objection to contacting their GP and clinicians
9. Currently taking part in another drug trial or expected change in medication during the trial
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
Oxford Brookes University
Gipsy Lane Headington
Trial participating centre
John Radcliffe Hospital
Multiple Sclerosis Society
Funding Body Type
private sector organisation
Funding Body Subtype
professional associations and societies
Results and Publications
Publication and dissemination plan
At the close of the trial, participants who have expressed interest in knowing the results of the study will be contacted, and MS support groups throughout Oxfordshire will be attended to present results. The results will be analysed, and written up for publication to relevant medical scientific journals. Results will also be presented at relevant conferences and to local clinicians (journal club at the OUH sites in which we are already scheduled to present about study).
Intention to publish date
Participant level data
Stored in repository
Basic results (scientific)
2018 protocol in: https://www.ncbi.nlm.nih.gov/pubmed/29403649