The document discusses postprandial hypersomnolence, also known as "food coma". It provides the physiological mechanisms that cause food-induced sleepiness, including increased levels of adenosine, parasympathetic activation, insulin and tryptophan levels, and insulin-induced hypokalemia. It then discusses an audit conducted at Barts-MS that found people with multiple sclerosis experience food coma more severely than others, with severity correlated to MS severity. People with MS reported making dietary changes and using caffeine to reduce symptoms.

1. Food Coma
Or
Postprandial Hypersomnolence
MS TRUST CONFERENCE 2020
Gavin Giovannoni

2. Disclosures
No relevant conflicts of interest in relation to this specific presentation.
Over the last 5 years I have received personal compensation for participating in
advisory boards in relation to clinical trial design, trial steering committees, and
data and safety monitoring committees from: Abbvie, Atara Bio, Biogen, Canbex,
Sanofi-Genzyme, Genentech, GSK, MSD, Merck KGaA, Novartis, Roche,
Synthon BV and Teva.

3. Definition

5. Siesta
Syndrome
The Hammock, by Gustave
Courbet (1844)

6. Science

7. “The great tragedy of science - the slaying of a beautiful hypothesis by an ugly fact.”
Thomas Huxley
4 May 1825 – 29 June 1895

9. The physiology of food coma
1. Adenosine and hypocretin/orexin
a. Glucose concentration stimulate ventrolateral preoptic nucleus of the hypothalamus via astrocytic release of adenosine
b. Orexin-expressing neurons appear to be hyperpolarized (inhibited) by a glucose-activated potassium channel. This
inhibition is hypothesized to then reduce output from orexigenic neurons to aminergic, cholinergic, and glutamatergic
arousal pathways of the brain, thus decreasing the activity of those pathways.
2. Parasympathetic activation
a. In response to food in the stomach and small intestine, parasympathetic nervous system is stimulated and the activity of
the sympathetic nervous system decreases.
b. This shift in the balance of autonomic tone leads to a subjective state of low energy and a desire to be at rest
3. Insulin, large neutral amino acids, and tryptophan
a. High glycemic index foods raise insulin levels which stimulates the uptake of valine, leucine, and isoleucine into skeletal
muscle, but not uptake of tryptophan.
b. Tryptophan becomes preferentially available to the large neutral amino acid transporter at the blood–brain barrier.
c. Tryptophan is converted to serotonin and melatonin, which result in sleepiness.
4. Insulin-induced hypokalemia
a. Insulin increases the activity of Na/K ATPase, causing increased movement of potassium into cells from the extracellular
fluid.
b. The effects of hypokalemia can include fatigue.
https://en.wikipedia.org/wiki/Postprandial_somnolence

10. Diabetes, December 24, 2014.
sugar / glucose / carbohydrates / insulin

12. Per capita sugar consumption (UK & USA)
R.J. Johnson, et al.: Am J Clin Nutr 86:899 –906, 2007.

13. Index cases

14. Index case
47 year old women with SPMS
My index patient is so affected by PPS that she now only eats one meal a day; her evening meal. She
does this quite late so that she can crash and sleep about an hour after eating.
She is a professional and needs to be functional during the day and finds if she eats anything substantial
in the day she simply can’t work because of her overwhelming desire to sleep. We have tried caffeine,
modafinil and amantadine to counteract PPS, but they only had a small effect in counteracting her PPS
and allowing her to work productively.
She finds carbohydrate-rich foods particularly potent at inducing ‘food coma’ and now avoids them.
She weighs 47 kg with BMI of 17

15. Social media

16. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

17. Blog survey

18. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

19. No Severe and
incapacitating
https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

20. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

21. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

22. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

23. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

24. https://multiple-sclerosis-research.org/2019/01/food-coma-does-it-affect-you/

25. Barts-MS audit

26. Objectives
1. Confirm blog online survey that found 85% of pwMS reported suffering from
PPS
2. As this phenomenon had not been formally studied before, and is a
potentially burdensome symptom for pwMS, we decided to do an audit in
order to:
i. Compare whether pwMS suffer from PPS more than people without MS (pw/MS)
ii.Examine whether the severity of PPS is correlated to the severity of MS
iii.Obtain information on the treatments pwMS are using and how effective these
treatments have been
Slide courtesy of Tatiana Christmas and Neena Singh

27. Methodology
▪ Qualitative research was conducted using an online survey, emailed to 350
pwMS from Barts-MS
▪ Their siblings, partners and friends were also asked to complete a similar
survey for the general population to allow comparison between the two
groups.
▪ Participants were asked to complete the survey one hour after eating lunch.
▪ Link to the survey for people with
MS: https://forms.gle/xZskX1pCKJwUDFJZ9
Slide courtesy of Tatiana Christmas and Neena Singh

28. Methodology
▪ The Stanford Sleepiness Score was used to objectively assess degree of
Postprandial Somnolence.
Slide courtesy of Tatiana Christmas and Neena Singh

29. Results
Frequency of Stanford Sleepiness Score
Cohort characteristics
1. The mean SSS for pwMS was 3.46, whilst the mean
SSS for pw/MS was 2.52 (p=0.001).
2. The mean SSS for pwMS who didn’t describe having
fatigue as a symptom was 2.80.
Slide courtesy of Tatiana Christmas and Neena Singh

30. Results
● From the pwMS, 18% felt their PPS
started after anything they ate, 61% after
an average meal, 22.4% after a slightly
large meal and 18.2% after a very large
meal.
● From the pw/MS, 12.5% started after
eating anything, 12.5% after an average
sized meal, 50% after a slightly large
meal and 25% after a very large meal.
● 63% of pwMS reported making changes to their diet to help their
symptoms, these included
○ reducing the portion size
○ the number of portions eaten in a day
○ reducing the amount of specific food components consumed,
specifically carbohydrates and fat.
● Caffeine and exercise were also commonly used, with 20% and 13% of
pwMS reporting having tried these as
● Solutions to improve their symptoms of PPS
Slide courtesy of Tatiana Christmas and Neena Singh

31. Quotable Quotes!
Slide courtesy of Tatiana Christmas and Neena Singh

32. Conclusions

33. Discussion
1. PwMS are affected by PPS more than control subjects - more people with MS subjectively felt that they suffered
from the phenomenon than the general population, but we have also been demonstrated this objectively using
the SSS.
2. It is well established that pwMS suffer from fatigue more than the general population, but it is clinically useful to
determine whether PPS is a major factor during their daily routines as tailored advice could be given to help with
this.
3. pwMS are adopting self-management strategies to help reduce their symptoms of PPS, the most commonly
used intervention was caffeine, however patients are making changes to their diet to improve their symptoms
which has had varying effects on their symptoms
a. Smaller portion sizes
b. Intermittent fasting
c. Low carbohydrate diet / low glycaemic index diets
d. Caloric restriction / ketogenic diets
4. Moving forward
a. Larger sample size is needed to make the project more robust
b. We now plan to study the effect of specific food groups on PPS symptoms via glucose/insulin response
curve.
5. #AntiSugar

34. https://medium.com/@gavin_24211/evolutionary-medicine-why-low-fat-diets-are-bad-for-you-95922f2f1999

36. Tatiana Christmas, Gavin Giovannoni and Neena Singh, MS Academy Masterclass 7

37. www.ms-res.org / www.clinicspeak.com / www.msbrainhealth.org
Twitter @GavinGiovannoni / www.medium.com/@gavin_24211
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38. Questions