What's the Best Diet to Control Multiple Sclerosis?

Which is the best diet for multiple sclerosis (MS) is one of the most common questions I get. Unfortunately, too many neurologists are stilling their patients that there is no research showing diet makes no difference for people with MS. They are wrong. I do clinical research testing the effects of diet in people with MS. Our studies have included the modified Paleolithic diet (also known as the Wahls™ diet), the ketogenic diet, and the low saturated fat diet (also known as the Swank diet).^1-7

What We’ve Found

Our studies have found that following the Wahls™ diet led to reductions in fatigue,^1,2,6-8 anxiety⁴, and depression,⁴ improved quality of life,^1,2,4,6,7 and improved walking, hand function, and mental clarity.^2-4,6,7 Adopting the Swank diet led to improved quality of life and reduced fatigue.⁶
I have published over 90 peer-reviewed scientific papers, abstracts, and posters and have conducted 8 clinical trials in people with MS. There have now been 12 randomized, controlled, dietary intervention studies in people with MS. Our MS diet studies have been cited by other scientists hundreds of times. There was a recent editorial in Neurology, the highest-impact journal that publishes MS research, stating there is now evidence that for people with MS, diet can reduce fatigue and improve quality of life. I am smiling. This is huge.

The strongest evidence that an intervention is helpful (or harmful) is when multiple studies are combined and analyzed together. This type of study is called a meta-analysis. A network meta-analysis combines all known studies and compares them to tell us which treatments are the most effective. There have been enough studies that examined the role of diet on fatigue and quality of life to conduct these important meta-analyses.

This meta-analysis, Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systemic Review and Network Meta-analysis of Randomized Trials⁹, was published in Neurology, the most widely read journal by practicing neurologists, in January 2023. One of my colleagues, Dr. Linda Snetselaar, conducted a network meta-analysis of randomized dietary intervention studies in MS that lasted at least 12 weeks and had either fatigue or quality of life as an outcome and lasted at least 12 weeks. There were 12 dietary intervention studies and 8 diets included in the analysis. The diets studied included Mediterranean, Paleolithic, ketogenic, anti-inflammatory, low-fat, fasting, calorie restriction, and control diet (the participant continued their usual diet). The low-fat diet group included a study of a low-fat vegan diet and a study of the low-fat Swank diet. A total of 608 people with MS were included in these 12 studies. The standardized mean difference (SMD) was calculated to measure how much the mental and physical quality of life or fatigue changed for the intervention diet and the control diet.

The SMD lets you measure how helpful each diet compared to the other diets. That is how scientists rate the effectiveness of the intervention from most effective to least effective. In studies like this, the 95% confidence interval (CI) is calculated for the intervention diet and the control diet. If the improvements and the 95% CI are entirely on the side that favors the intervention, then we can say the intervention is effective in helping fatigue and or quality of life.

When comparing each intervention diet to the control diet, three intervention diets had confidence intervals that were entirely on the side favoring the intervention The magnitude of change for reducing fatigue severity in descending order, was Paleolithic (SMD: -1.27; 95% CI: -1.81, -0.74), low-fat diet (SMD: -0.90; 95% CI: -1.39, -0.42), and Mediterranean, (SMD: -0.89; 95% CI: -1.15, -0.64). When comparing each diet to the usual diet for improving quality of life, there were two diets that were associated with significant improvement in quality of life. In descending order, those two diets were the Paleolithic (SMD: 1.01; 95% CI 0.40, 1.63) and Mediterranean (SMD: 0.47; 95% CI 0.08, 0.86) diets. The Paleolithic diet studies cited in the network meta-analysis and half the low-fat diet studies were from our lab. The Paleolithic diet was the Wahls™ diet and the low-fat diets were the Swank and the low-fat vegan diet also known as the McDougall diet.

The Paleolithic diet group had about a 30% greater reduction in fatigue than the other two diet groups and about twice the improvement in quality of life compared to the Mediterranean diet. I am not surprised the largest effect size was with the Paleolithic diet. The three most common food antigens (gluten, casein, and egg albumin) that cause excessive activation of the immune system are removed in the modified Paleolithic diet that we have investigated in multiple studies. The Paleolithic diet and Mediterranean diets have many common features, including less added sugar, less ultra-processed foods, and more non-starchy vegetables.

The Neurology editorial noted above, The Role of Diet in Multiple Sclerosis: Food for Thought¹⁰, appeared in the same issue as Dr. Snetselaar’s meta-analysis. The editorial said that all MS patients should be told that diet influences fatigue and quality of life. Neurologists could send their MS patients to registered dietitians (RD). A visit with an RD for guidance and support for improving one’s diet is likely to be covered by most health insurance plans.

This is huge. The Wahls™ (modified Paleolithic) diet is no longer dangerous. Now, well-respected MS researchers are saying all MS patients should be told to adopt one of these three diets as part of their wellness plan to better manage MS symptoms and have a better disease course.

The reason the other diets were not found to be helpful for reducing fatigue and improving quality of life is that the 95% confidence interval crossed over the line in which the control diet is more beneficial than the intervention diet. The diet was associated with worse fatigue and poorer quality of life was calorie restriction (reducing calories to less than 70% of what is needed metabolically, leading to weight loss and chronic sense of hunger). The ketogenic diet, intermittent fasting, and anti-inflammation diets had a modest improvement in quality of life and/or reduction in fatigue, but the 95% confidence interval crossed the line showing the control diet to be better than the intervention diet. Larger studies of those various diets might shrink the 95% confidence interval enough so that the 95% confidence interval is on the side of the intervention diet.

What does all this mean for people with MS?

The most exciting thing is that your diet quality matters. There are several diets that have been studied that have been shown to help improve quality of life, reduce fatigue, and improve function. When I meet with my patients I advocate for a family intervention that addresses the patient’s comorbid medical issues, can help with their MS-related symptoms, and feels doable for the family. Factors that I consider are the risk for developing insulin resistance, metabolic syndrome, pre-diabetes, diabetes, mental health symptoms, and risk for developing orthorexia, which is a fixation and rigidity about which foods to eat and which foods to avoid that can lead to excessive restriction on foods. I tell them the diet that has the strongest evidence for benefit — but it is important to consider what is actually achievable. The key elements of the three best diets for MS are summarized next.

Mediterranean

• Encourages more vegetables and fruits, whole grains, legumes, fish, nuts, and seeds
• Reduces or eliminates added sugars, processed foods, fast foods, white breads, and white rice

Low saturated fat (Swank)

• Encourages more vegetables, fruits, whole grains, fish, and white poultry
• Restricts saturated fat to less than 15 grams per day
• Restricts red meat, dark poultry meat, dairy fat, and saturated fat
• Reduces or eliminates added sugar, processed foods, and fast foods
• Low saturated fat vegan (McDougall) diet or plant-based low-fat diet
• Encourages more vegetables, fruits, whole grains, legumes
• Restricts saturated fat to less than 10 grams per day
• Restricts animal products (meat, dairy, eggs)
• Reduces or eliminates added sugar, processed foods, and fast foods

Modified Paleolithic (Wahls)

• Encourages more vegetables (target is 6 to 9 servings), 6 to 12 ounces of meat or fish, fermented foods, nuts, and seeds
• Excludes gluten-containing grains, dairy, and eggs
• Reduces or eliminates added sugars, processed foods, fast foods, and grains

The common theme for these three diets is eating more non-starchy vegetables and less fast foods and less processed foods.

Other Diets That Have Been Studied in MS or in a Variety of Other Health Issues

Ketogenic^11-14

• Encourages fat target 100 grams 70 to 90 %of calories from fat sources
• Moderate amount of protein (50 to 100 grams of protein or 6 to 12 ounces of meat, fish per day)
• Restricts carbohydrates to 25 to 35 grams per day
• Often stresses eggs and dairy
• May utilize a modified Atkin’s diet
• In our studies, we encourage olive oil instead of dairy fats.
• Eliminates added sugars, processed foods, fast foods, and grains.
• Helpful for improving blood sugar levels and insulin sensitivity

Intermittent fasting^15,16

• 5:2 plan
• 2 days a week restricts diet to approx. 500 calories
• 5 days a week usual diet but does not increase calories
• Does not restrict diet during the 5-day usual diet portion of the week other than to not increase calories
• Leads to an overall reduction in calories about 20% consumed in the week
• More difficult to sustain long-term than time-restricted eating
• Helpful for improving blood sugar levels and insulin sensitivity

Time-restricted eating¹⁷

• 4 to 8-hour eating window
• 16 to 20-hour not eating window
• Easier to sustain long-term than intermittent fasting
• Low level ketosis is achieved briefly each day during the not eating window.
• Improves insulin sensitivity and circadian rhythm

Anti-inflammatory diet¹⁸

• Often is a gluten-free diet
• Encourages vegetables, nuts, fish
• May reduce dairy or nightshade vegetables
• Reduces or eliminates added sugars, processed foods, fast foods, and grains.

Next Steps

How will the family support the person with MS? It is much easier when the family eats the same meal in the presence of the person with MS. When they are consuming a meal away from the person with MS – they eat what they want to eat that the person with MS has now decided to exclude from the diet. Reducing sugar and white flour-based (ultra-processed foods) is associated with better health for everyon . Thee is less risk of cognitive impairment, anxiety, depression, Alzheimer’s, Parkinson’s, MS, learning disability, rage, violence, obesity, high blood pressure, insulin resistance, pre-diabetes, and diabetes.

It is better for everyone in the family.

Get everyone involved in food preparation, meal planning, and clean-up. Chores are good for children’s self-esteem, and good for the family. Talk to the family about why the changes are being made so they understand why the changes are occurring.

I tell my students and post-doctoral research scholars that changing the standard of care takes 30 years. I am 15 years into this journey. My big audacious goal is to have diet become part of the standard of care for MS — that patients are told that diet matters and are encouraged to improve their diet to protect their brains. For that to happen we need more published, peer-reviewed scientific studies. I am doing that research. I need people like you to come to Iowa and be part of our clinical trials! We can change the world together.

Much of my research has been supported by donations from the public. We have received donations from people like you and from grateful patients whose lives I’ve changed. You can learn more about how you contribute to our innovative research program here.

Citations

1. Bisht B, Darling WG, Grossmann RE, et al. A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med. 2014;20(5):347-355.
2. Bisht B, Darling WG, Shivapour ET, et al. Multimodal intervention improves fatigue and quality of life in subjects with progressive multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2015;5:19-35.
3. Bisht B, Darling WG, White EC, et al. Effects of a multimodal intervention on gait and balance of subjects with progressive multiple sclerosis: a prospective longitudinal pilot study. Degener Neurol Neuromuscul Dis. 2017;7:79-93.
4. Lee JE, Bisht B, Hall MJ, et al. A multimodal, nonpharmacologic intervention improves mood and cognitive function in people with multiple sclerosis. J Am Coll Nutr. 2017;36(3):150-168.
5. Lee JE, Titcomb TJ, Bisht B, Rubenstein LM, Louison R, Wahls TL. A modified MCT-based ketogenic diet increases plasma beta-hydroxybutyrate but has less effect on fatigue and quality of life in people with multiple sclerosis compared to a modified Paleolithic diet: a waitlist-controlled, randomized pilot study. J Am Coll Nutr. 2021;40(1):13-25.
6. Wahls TL, Titcomb TJ, Bisht B, et al. Impact of the Swank and Wahls elimination dietary interventions on fatigue and quality of life in relapsing-remitting multiple sclerosis: the WAVES randomized parallel-arm clinical trial. Mult Scler J Exp Transl Clin. 2021;7(3):20552173211035399.
7. Irish AK, Erickson CM, Wahls TL, Snetselaar LG, Darling WG. Randomized control trial evaluation of a modified Paleolithic dietary intervention in the treatment of relapsing-remitting multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2017;7:1-18.
8. Reese D, Shivapour ET, Wahls TL, Dudley-Javoroski SD, Shields R. Neuromuscular electrical stimulation and dietary interventions to reduce oxidative stress in a secondary progressive multiple sclerosis patient leads to marked gains in function: a case report. Cases J. 2009;2:7601.
9. Snetselaar LG, Cheek JJ, Fox SS, et al. Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systematic Review and Network Meta-analysis of Randomized Trials. Neurology. 2023;100(4):e357-e366.
10. Spain RI, Piccio L, Langer-Gould AM. The Role of Diet in Multiple Sclerosis: Food for Thought. Neurology. 2023;100(4):167-168.
11. Lee JS, Auyeung TW, Leung J, Kwok T, Leung PC, Woo J. Physical frailty in older adults is associated with metabolic and atherosclerotic risk factors and cognitive impairment independent of muscle mass. J Nutr Health Aging. 2011;15(10):857-862.
12. Bahr LS, Bock M, Liebscher D, et al. Ketogenic diet and fasting diet as Nutritional Approaches in Multiple Sclerosis (NAMS): protocol of a randomized controlled study. Trials. 2020;21(1):3.
13. Abboud M, AlAnouti F, Georgaki E, Papandreou D. Effect of Ketogenic Diet on Quality of Life in Adults with Chronic Disease: A Systematic Review of Randomized Controlled Trials. Nutrients. 2021;13(12).
14. Brenton JN, Lehner-Gulotta D, Woolbright E, et al. Phase II study of ketogenic diets in relapsing multiple sclerosis: safety, tolerability and potential clinical benefits. J Neurol Neurosurg Psychiatry. 2022;93(6):637-644.
15. Lin X, Wang S, Gao Y. The effects of intermittent fasting for patients with multiple sclerosis (MS): a systematic review. Front Nutr. 2023;10:1328426.
16. Lorefice L, Pitzalis M, Zoledziewska M. Intermittent and periodic fasting - Evidence and perspectives in multiple sclerosis. Mult Scler Relat Disord. 2024;88:105744.
17. Pivovarova-Ramich O, Zimmermann HG, Paul F. Multiple sclerosis and circadian rhythms: Can diet act as a treatment? Acta Physiol (Oxf). 2023;237(4):e13939.
18. Mousavi-Shirazi-Fard Z, Mazloom Z, Izadi S, Fararouei M. The effects of modified anti-inflammatory diet on fatigue, quality of life, and inflammatory biomarkers in relapsing-remitting multiple sclerosis patients: a randomized clinical trial. Int J Neurosci. 2021;131(7):657-665.