Does Your Neurologist Still Tell You There Is No Research to Support Dietary Interventions for MS? They’re Wrong.

In this blog I will review what the research actually shows and provide a short breakdown of the different dietary approaches that have been shown to impact some of the symptoms associated with MS. These findings are likely to apply across multiple types of autoimmune disease as well, but there have been more research studies specifically focused on MS than other autoimmune conditions.

I conduct clinical research specifically 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

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 100 peer-reviewed scientific papers and have conducted 8 clinical trials in people with MS. Our diet studies have been cited by other scientists hundreds of times. And recently, an editorial appeared in Neurology, the most widely read journal by practicing neurologists, stating that there is now evidence that diet can reduce fatigue and improve quality of life for people with MS.

I am smiling. This is huge.

Meta-Analyses: The Strongest Research Supports Three Dietary Approaches for Improving MS Symptoms

A network meta-analysis combines all known studies on a topic and compares them to determine which interventions are most effective. In these studies, a standardized mean difference (SMD) is calculated to measure how much the outcome of interest (in this case, chronic fatigue and quality of life in people with MS) changed compared to the control. That is how scientists rate the effectiveness of the intervention — from most effective to least effective.

There have now been enough studies on the role of diet in fatigue and quality of life to conduct such a study — and in January 2023, my colleague Dr. Linda Snetselaar published a network meta-analysis in Neurology examining how different diets affect fatigue and quality of life in people with MS.⁹ The analysis included 12 dietary intervention studies, 8 different diets, and a total of 608 people with MS. The diets studied included Mediterranean, Paleolithic, ketogenic, anti-inflammatory, low-fat, fasting, calorie restriction, and a control diet (participants continued their usual eating habits).

For reducing fatigue, three diets showed clear benefit. In order of effectiveness:

• Paleolithic diet (strongest effect)
• Low-fat diet
• Mediterranean diet

For improving quality of life, two diets showed significant benefit:

• Paleolithic diet (strongest effect)
• Mediterranean diet

The Paleolithic diet was more than twice as effective as the Mediterranean diet at improving both physical and mental quality of life.

The Paleolithic diet studies in this meta-analysis were from our lab — the Wahls™ diet. The low-fat diet studies included the Swank diet and the low-fat vegan McDougall diet.

Why Does Paleo Outperform the Mediterranean or Low Saturated Fat Diets? 

The Paleolithic and Mediterranean diets have a lot in common, including less added sugar, less ultra-processed foods, and more non-starchy vegetables. (When we studied the low saturated fat diet, we also encouraged more vegetables and whole grains.)

All three diets in the clinical trials encourage more vegetable consumption — but only the Paleolithic diet completely removes the most common food antigens (gluten, casein, and egg albumin) that cause excessive activation of the immune system.

In my opinion, this is why a Paleo diet consistently outperforms the other diets for reducing fatigue and improving quality of life.

Neurology Editorial: The Role of Diet in Multiple Sclerosis: Food for Thought¹⁰

This editorial appeared in the same issue as Dr. Snetselaar’s meta-analysis, and stated that all people with MS should be told that diet influences fatigue and quality of life, and that neurologists should consider referring their patients to registered dietitians (RDs) for support. A visit with an RD is likely to be covered by most health insurance plans.

This is a meaningful shift. The Wahls™ Diet (modified Paleolithic), once considered fringe, is now being recognized by well-respected MS researchers as part of a legitimate wellness plan for managing MS symptoms and supporting a better disease course.

The Three Best-Supported Diets for MS: A Quick Overview

The most exciting takeaway of all this is that the quality of your diet matters. When I meet with my patients, I advocate for a family intervention that can help with their MS-related symptoms while still feeling doable for the whole family.

Below you’ll find a high-level breakdown of the three diets that have shown to be most effective for impacting chronic fatigue and quality of life.

Modified Paleolithic (Wahls™)

• Encourages more vegetables (6–9 servings), 6–12 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.

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

The common thread across all three: more non-starchy vegetables, fewer processed foods, less added sugar.

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

Other Diets That Have Been Studied in MS

Ketogenic^11-14

• Encourages 70–90% of calories from fat sources (or 100 grams daily)
• Moderate amount of protein (50– 100 grams of protein or 6– 12 ounces of meat, fish per day)
• Restricts carbohydrates to 25–35 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
• Restricts diet to approx. 500 calories 2 days/week
• Does not restrict diet during the remaining 5 days 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

• 4–8-hour eating window;
• 16–20-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.

How To Choose The Right Diet for You

The best diet is ultimately one you can actually sustain. When I work with patients, I advocate for a family-based approach that addresses their specific health concerns, supports their MS symptoms, and feels realistic for their household.

Some questions I consider:

Is there a history of an eating disorder?
Some diets involve more restriction than others, and rigid food rules can be harmful for people with a history of orthorexia or disordered eating.

What are the comorbid health issues?
Evidence of insulin resistance, metabolic syndrome, pre-diabetes, or type 2 diabetes may point toward a lower-carbohydrate approach.

What does the family eat?
It's much easier to sustain dietary changes when the whole family participates — or at least supports the person with MS. When family members eat meals together, it helps. When they're eating differently away from home, that's fine too, as long as the household meals are supportive.

The bottom line:
Reducing sugar and white flour-based foods benefits everyone in the household, not just the person with MS. More vegetables and less sugar will lower the risk of cognitive impairment, anxiety, depression, Alzheimer's, Parkinson's, learning difficulties, obesity, high blood pressure, and diabetes for children and adults alike.

Helpful Supplements to Support Your Nutrition

The enzymes that fuel your cellular chemistry require adequate vitamin and mineral intake. Unfortunately, many Americans have had suboptimal diets for years and may have significant insufficiencies for multiple vitamins and minerals.

In addition to dietary changes, I routinely recommend taking a few targeted supplements to support your nutrition: Vitamin D3 plus vitamin K2, Multivitamin/ Multimineral, Magnesium and Fish Oil.

You can purchase these all together in a Basic Support kit for convenience.

Closing Thoughts: Changing Medical Culture Takes Time

I tell my students and research scholars that changing the standard of care takes about 30 years. I am 16 years into this journey myself, and my big, audacious goal is to make diet part of the standard of care for MS. I want every patient to be told that what they eat matters, and to be supported in making the dietary changes that will protect their brain.

Much of this research has been made possible by donations from people like you and from grateful patients. You can learn more about how to support our 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.