RSS

Restless Leg Syndrome: Is Your Diet Related?

23 Apr

As an everyday part of my sleep practice, I often see patients who complain of problems falling asleep due to symptoms in their legs when they get in bed. It can be anything from “restlessness” to “deep pain” in the legs, but almost always follows a typical pattern. What these patients suffer from is called Restless Leg Syndrome (RLS), and it is more common than you may think. Lets learn a little about it, and investigate whether or not diet can either lead to, or relieve the symptoms of this often misunderstood condition.

Epidemiology: The numbers vary widely in the literature as far as the overall prevalence of RLS across the population, but it’s safe to say 5-10% of Americans suffer from some form of RLS throughout their lives. Importantly, this is not just a disease of adults, as it is felt that the overall prevalence is similar in children as well. In these children, RLS symptoms are often misdiagnosed as “growing pains” and the sleep disruption it causes often leads to night after night of unrestful and disjointed sleep. When adults get tired we get sleepy, when kids get tired they get cranky, agitated, disruptive, and even hyper. Needless to say, many experts believe unrecognized RLS in kids could account for a good number of cases labeled as ADHD. As in many things in sleep medicine, this remains controversial.

Pathogenesis: RLS can be grouped into two main categories, as can many disease states; it is either primary or secondary.

Primary RLS is idiopathic, meaning there is no real identifiable cause. Observational studies point to it being a genetic disease with autosomal dominant inheritance. The underlying genetic defect occurs somewhere in the metabolism of dopamine in the central nervous system, although imaging studies using SPECT and PET imaging of dopamine producing areas have produced often conflicting data. Given that Parkinson’s disease is clearly known to be related to dopamine defects in the CNS, and the fact that Parkinson’s medicines have been successfully used to treat RLS, this is an important area of current research in Neuroscience.

Secondary RLS is felt to be caused by a number of other conditions; in other words, RLS is a symptom of these problems. Here are a few of the most common (and the one we are most interested in).

-Iron Deficiency – Since the original description of RLS, iron deficiency has been considered one of the most likely causes. Study after study have consistently showed decreased iron stores (ferritin) in RLS patients vs. controls. MRI estimates of brain iron concentration in the substantia nigra (the area that makes dopamine) have also been consistently lower in RLS patients. That said, these findings are FAR from universal, so it is only part of the story.

End-Stage Renal Disease – If you take care of hemodialysis patients for very long, you quickly hear the same complaints of RLS pop up time after time. The cause of RLS in these patients has many theories, from iron deficiency to low parathyroid hormone (PTH) levels. Research is ongoing.

Diabetes Mellitus – RLS often co-exists with peripheral neuropathy and can be quite debilitating.

Multiple Sclerosis – The data on RLS and MS is in its infancy, but I can tell you that over half of my MS patients have clear RLS. There is a connection.

Parkinson’s Disease – Although dopamine is related to both conditions, studies have failed to consistently find a link between RLS and Parkinson’s. This is frustrating as both disorders clearly point to the substantial nigra in the CNS as to location of disease. Our hope is that a breakthrough in one disease will lead to a ray of hope in the other. Only time will tell…

-There are many other disease states related to RLS, and often listed in the miscellaneous file are vitamin deficiencies and obesity. We’ll talk more about them later.

Clinical Manifestations and Diagnosis: Here is how UpToDate.com describes RLS.

Although the subjective symptoms of RLS are often difficult to describe, the clinical features are highly stereotyped. The hallmark of RLS is a marked discomfort in the legs that occurs only at rest and is immediately relieved by movement. The abnormal feelings are typically deep seated and localized below the knees. Distribution is usually bilateral, but some asymmetry may occur and the arms can be affected in more severe cases.

Terms that patients use to describe the symptoms include crawling, creeping, pulling, itching, drawing, or stretching, all localized to deep structures rather than the skin. Pain and tingling paresthesia of the type that occurs in painful peripheral neuropathy are usually absent, and there is no sensitivity to touching of the skin.

Symptoms typically worsen towards the end of the day and are maximal at night, when they appear within 15 to 30 minutes of reclining in bed. In severe cases symptoms may occur earlier in the day while the patient is seated, thereby interfering with attending meetings, sitting in a movie theater, and similar activities. In milder cases patients will fidget, move in bed, and kick or massage their legs for relief. Patients with more severe symptoms feel forced to get out of bed and pace the floor to relieve symptoms.

The International Restless Legs Study Group proposed the following four features as essential criteria for the diagnosis of RLS:

1) An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs. Sometimes the urge to move is present without the uncomfortable sensations, and sometimes the arms or other body parts are involved in addition to the legs.

2) The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.

3) The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.

4) The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night. When symptoms are severe, the worsening at night may not be noticeable but must have been previously present.

Dietary Treatment: There are tons of resources on the internet about standard pharmacologic treatment of RLS, and that is not the main topic of this post. What we are going to look at now is common non-pharmacologic treatments for RLS, in particular diet related treatments. Let’s see where this takes us!

According to the RLS Foundation there are multiple foods that should be avoided in order to minimize or eliminate RLS symptoms. These include caffeine, alcohol, ice cream, as well as pasta and bread.

Now you all know this is a Paleo blog, and are you seeing what I just saw? Pasta and bread??? Why? We all know why…say it with me…GLUTEN!

Both Celiac Disease(CD) and Gluten Sensitive Enteropathy (GSE) lead to abnormal small intestine mucosa due to inflammation. This inflammation leads to malabsorption, and this is the pathway which connects it with RLS. We saw above that a classic cause of secondary RLS is iron deficiency anemia. We all know gluten is indigestible by the human small intestine, and it causes some degree of inflammation for anyone who eats it. People with CD or GSE have pathologic inflammation in their gut, thus making it impossible for them to appropriately absorb dietary iron. Give these people long enough and their ferritin and iron levels get low enough to put them at risk for developing RLS symptoms.

So how related are CD and RLS? Lets look at some clinical data for answers. One study showed the incidence of RLS in CD patients to be 35%, of these, 40% also had iron deficiency. In another study, 31% of CD patients had RLS vs only 4% of the control group. Also, iron levels in this study were statistically significantly lower in the CD patients with RLS than in those without the disease. BUT, after all was said and done, no clear correlation was found in this study between RLS and either a gluten free diet or iron metabolism.

Yet another study showed that GSE antibodies were NOT associated with RLS unless there was an associated underlying anemia. Everyone confused yet?! Let’s look at one more thing before we try to figure all this out.

Interestingly enough, another commonly recognized cause of secondary RLS is magnesium deficiency. Many people with RLS are amazed to see a rapid resolution of symptoms simply by taking OTC magnesium supplements…but not all get relief. Why do some get relief, and some not? Why do very controlled studies show some people get complete resolution of RLS symptoms when adapting a gluten free diet, and other get no relief at all?

Conclusion: Lets say your mom has RLS, and her mom had RLS, and her dad had RLS…what are your chances? I would say pretty good. In this case, there is clearly a autosomal dominant gene being passed down through the generations causing RLS. That gene leads to a yet unknown defect in dopamine metabolism in the substantia nigra of your CNS, and thus to your RLS. Gluten is no where in this picture! Although many want to believe that Paleo can fix everything, it simply can’t. Lets say one day your car stops running, and after checking it over you realize it’s just out of gas! You fill her up and she fires right up. I think we would all agree that your view is skewed if you believe that no matter what happens to your car, if it stops running, all you need to do is put gas in and it will work. Gas is not the only necessary part of your car to make it run! Likewise, gluten is just a piece of the puzzle.

That said, gluten can be and often is an important issue to address in RLS. What is the pathway to a gluten free diet improving RLS symptoms? First of all, you have to have RLS that is secondary in nature, not primary. Next, the cause of your RLS needs to be either iron deficiency anemia or magnesium deficiency. (I by no means believe these are the only two nutritional causes of RLS, but they are the most common and most studied) Now, if your iron or magnesium deficiency is caused by malabsorption from CD or GSE, you may be in luck! This pathway explains why we have such variable results in studies concerning gluten, iron metabolism, and RLS. For someone’s RLS to respond positively to a gluten free diet they not only need to have an underlying gluten problem, but that problem must also be leading to clinical iron or magnesium deficiency. If we look at one of the studies above where the incidence of RLS in CD patients was 35%, and only 40% of those had iron deficiency; that means a gluten free diet will likely only help 40% of 35% of the original study population! Even that is if you get 100% response to the diet in those who are “primed” to respond.

One of my biggest messages I try to get out through my blog is that although adapting a Paleo diet can do amazing things for your life and for your health, it can not substitute for traditional Western medicine in every instance. If your RLS is related to dopamine (in other words, genetically handed down), and you want relief of your symptoms, it’s best if you see your doctor and get a prescription for medicines that will increase dopamine in your CNS. You can go gluten free forever and never get the results that you need. Do not become single minded, it won’t get you anywhere but walking around at midnight again frustrated and tired.

In the end RLS is a very important cause of morbidity in America, and around the world. How do I use this information in my practice?

-In RLS patients I often recommend a trial of gluten free diet to see how symptoms respond, particularly in patients with no family history of RLS, or a positive family history of CD.

-In iron deficiency anemia patients who fail to respond to iron replacement, I often test them for CD as an underlying cause of malabsorption.

Think you may have RLS? Talk to your doctor or contact a local board certified sleep physician to get evaluated. I often used to tell patients that RLS would not kill them, it would just make them want to kill themselves. Recent data showing how short sleep times, in and of themselves, can increase overall mortality has me changing my tune. That topic though…is for another blog post in the future!

I hope this post finds you all well, God Bless.

Ernie

PS – Because it’s fun to share, I thought I might give yall my two favorite “home remedies” that I’ve heard over the years for treating RLS. Now please, I DO NOT RECOMMEND THEM, just sharing. One gentleman told me his best method was putting homemade charcoal in a sock, smashing it up a bit, and rubbing the sock all over his legs before bed time. The blacker his legs got, the better he said he slept.

This can only be outdone by the man who told me after years of experimenting, he found that rubbing paint thinner on his legs at bedtime led to a nice sound sleep…….. I quickly made sure neither he or his wife smoked! You just can’t make this stuff up…!

Sources:

Restless Leg Syndrome Foundation: About RLS

UpToDate.com Section on RLS

Dig Dis Sci. 2010 Jun;55(6):1667-73. doi: 10.1007/s10620-009-0943-9.

Celiac disease is associated with restless legs syndrome.

Weinstock LB, Walters AS, Mullin GE, Duntley SP.

Source Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63141, USA

Mov Disord. 2010 May 15;25(7):877-81. doi: 10.1002/mds.22903.

Restless legs syndrome is a common feature of adult celiac disease.

Moccia M, Pellecchia MT, Erro R, Zingone F, Marelli S, Barone DG, Ciacci C, Strambi LF, Barone P.

Source Department of Neurological Sciences, University Federico II and IDC Hermitage Capodimonte, Naples, Italy.

Acta Neurol Belg. 2011 Dec;111(4):282-6.

Prevalence of gluten sensitive enteropathy antibodies in restless legs syndrome.

Cikrikcioglu MA, Halac G, Hursitoglu M, Erkal H, Cakirca M, Kinas BE, Erek A, Yetmis M, Gundogan E, Tukek T.

Source Department of Internal Medicine, Bezmialem Vakif University, Medical Faculty, Fatih, Istanbul, Turkey

Sleep Med. 2009 Aug;10(7):763-5. doi: 10.1016/j.sleep.2008.07.014. Epub 2009 Jan 12.

Celiac disease as a possible cause for low serum ferritin in patients with restless legs syndrome.

Manchanda S, Davies CR, Picchietti D.

Source University of Illinois at Urbana-Champaign, College of Medicine, 506 S. Mathews Avenue, Suite 190, Urbana, IL 61801, USA.

 
8 Comments

Posted by on April 23, 2013 in General Paleo Discussion

 

Tags: , , , ,

8 responses to “Restless Leg Syndrome: Is Your Diet Related?

  1. Ted M

    April 23, 2013 at 9:16 am

    Magnesium! Over 75% of the population is deficient in Mag and many can be helped with RLS by bringing their Mag into line.

     
  2. Koanic

    April 23, 2013 at 9:27 am

    Fastest cure is eating some scallops or other saltwater seafood, as long as it’s not being caused by e.g. gluten or other food intolerances.

     
  3. thepaleospot

    April 23, 2013 at 10:22 am

    I have (self-diagnosed) RLS. I did notice some difference once I removed grains from my diet. Unfortunately, the RLS got worse again after I started exercising more. It’s like now that they know how it feels to really move, they want to move all of the time! It is quite distracting at work and causes me to get up and walk around and squat quite frequently. When I am not doing that, my legs just bounce constantly. Great information, thank you for sharing!

     
  4. A. Weber

    April 25, 2013 at 6:35 pm

    I just stumbled across this post as a medical student interested in primary care despite our very “specialized” medical world. While we have different opinions on many matters your compassion for your patients shines in your posts and it is clear you are someone who is working to continually improve your practice.

    I noticed you often back up many of your posts with citations. I am curious about your feelings towards the latest NEJM on the Mediterranean diet? Do you know of any large scale randomized Paleo diet trials? I haven’t been able to find any yet.

    I know that cost is a huge factor for large scale trials but personally I feel like I cannot support a true Paleo diet for patients until there is quality research supporting it is in fact superior to a Mediterranean diet. Certainly, the crossover between these diets is pretty immense so what do you see as the superior benefits of a Paleo diet?

    I’m interested to hear your thoughts or get some articles? Thanks!

    By the way, I really enjoyed your Physician’s Manifesto – I find myself often having to justify medications and Western medicine to Paleo friends. I think many people that adopt this attitude come from upper socioeconomic backgrounds (i.e. above median income of 40,000) where they fail to realize how vulnerable many people in our society are and how few choices are available to them. We all know health is in part due to self-will in diet and exercise but we need to recognize that for many individuals to succeed they are up against extraordinary odds. Compassion and education are in order not judgement and dismissal.

    -SouthernMed

     
  5. southernmed

    April 25, 2013 at 6:37 pm

    I just stumbled across this post as a medical student interested in primary care despite our very “specialized” medical world. While we have different opinions on many matters your compassion for your patients shines in your posts and it is clear you are someone who is working to continually improve your practice.

    I noticed you often back up many of your posts with citations. I am curious about your feelings towards the latest NEJM on the Mediterranean diet? Do you know of any large scale randomized Paleo diet trials? I haven’t been able to find any yet.

    I know that cost is a huge factor for large scale trials but personally I feel like I cannot support a true Paleo diet for patients until there is quality research supporting it is in fact superior to a Mediterranean diet. Certainly, the crossover between these diets is pretty immense so what do you see as the superior benefits of a Paleo diet?

    I’m interested to hear your thoughts or get some articles? Thanks!

    By the way, I really enjoyed your Physician’s Manifesto – I find myself often having to justify medications and Western medicine to Paleo friends. I think many people that adopt this attitude come from upper socioeconomic backgrounds (i.e. above median income of 40,000) where they fail to realize how vulnerable many people in our society are and how few choices are available to them. We all know health is in part due to self-will in diet and exercise but we need to recognize that for many individuals to succeed they are up against extraordinary odds. Compassion and education are in order not judgement and dismissal.

     
  6. southernmed

    April 25, 2013 at 6:42 pm

    I just stumbled across this post as a medical student interested in primary care despite our very “specialized” medical world. While we have different opinions on many matters your compassion for your patients shines in your posts and it is clear you are someone who is working to continually improve your practice.

    You are clearly operating a very evidence-based practice so I am curious about your feelings towards the latest NEJM on the Mediterranean diet? Do you know of any large scale randomized Paleo diet trials? I haven’t been able to find any yet.

    I know that cost is a huge factor for large scale trials but personally I feel like I cannot support a true Paleo diet for patients until there is quality research supporting it is in fact superior to a Mediterranean diet. Certainly, the crossover between these diets is pretty immense so what do you see as the superior benefits of a Paleo diet?

    I’m interested to hear your thoughts or get some articles? Thanks!

    By the way, I really enjoyed your Physician’s Manifesto – I find myself often having to justify medications and Western medicine to Paleo friends. I think many people that adopt this attitude come from upper socioeconomic backgrounds (i.e. above median income of 40,000) where they fail to realize how vulnerable many people in our society are and how few choices are available to them. We all know health is in part due to self-will in diet and exercise but we need to recognize that for many individuals to succeed they are up against extraordinary odds. Compassion and education are in order not judgement and dismissal.

     
  7. Deborah Leddon

    April 29, 2013 at 10:00 am

    Thanks for putting up this post Doc. Amazing information. Just FYI: I have nasty case of RLS and am under a ‘Probable MS diagnosis after extensive screening. I am being treated for it as MRI’s show evidence though spinal screens do not (do have occasional lapses though not as severe). I also have Celiacs. Had a genetic test which confirmed Celiacs and RLS.

     
  8. Your Living Body

    May 10, 2013 at 12:33 pm

    I randomly came across your blog and love what I see. As a nurse, it’s great to see a MD buying into the paleo lifestyle for disease prevention. We need more healthcare practitioners like that in the field.

    Matt
    http://www.yourlivingbody.com

     

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

 
%d bloggers like this: