There is an overwhelming amount of information available about which diets are “best” for MS and other autoimmune conditions, and it can be hard to find the best approach for your unique circumstances. In this article, I’m going to share what I recommend for my patients, in the hopes that it offers some clarity.
As an internal medicine physician, I conduct nutrition research and clinical trials in the setting of multiple sclerosis (MS) and other chronic conditions. I also teach other clinicians, work directly with patients, and am the author of two books on the subject — and I live with secondary progressive MS myself.
There are several dietary plans that have been shown to improve energy and quality of life for people with MS, but the most important piece of the puzzle is that any dietary intervention needs to be personalized to address any underlying or additional medical issues.
Let’s start there.
The Mediterranean Diet is my go-to recommendation for people with no additional health issues. It is one of the easier diets to implement and maintain, and includes a variety of vegetables, legumes, fish, and healthy fats.
But most people do have additional health issues, and this is where personalization comes in.
How Blood Sugar, Metabolism and Insulin Sensitivity Should Factor into Your Dietary Approach
Forty percent of Americans have insulin resistance — they need a much higher level of insulin to maintain a healthy blood sugar level — but because there are no symptoms of insulin resistance, most people aren’t aware they have it. Insulin resistance increases the risk of metabolic syndrome and type 2 diabetes, both of which are linked to worse outcomes for people with MS, including earlier job loss and disability.
When insulin resistance occurs, the microglia (immune cells in the brain) shift to a more inflammatory state, causing increased damage to myelin, axons, and synapses. The result is an increased risk for developing new lesions, new relapses, and a shrinking brain and spinal cord.
When assessing potential dietary solutions, you need to know if you have insulin resistance, so you can factor that into your decision.
To find out, you can ask your primary care provider to order a fasting glucose and insulin lab. Ideally, fasting insulin should be below 6 µIU/mL, while a fasting insulin above 25 µIU/mL suggests insulin resistance is developing.
Alternatively, you can check your triglyceride:HDL cholesterol ratio from your most recent fasting blood cholesterol labs. If the ratio is less than two, you are very insulin sensitive. If it’s greater than four, you have insulin resistance and will likely benefit from eating a diet with fewer carbohydrates, like the paleolithic or ketogenic diet.
When to Try Paleolithic Eating (and Why)
When my patients have insulin resistance, metabolic syndrome, or type 2 diabetes, I recommend lowering the amount of carbohydrates in their diet.
Usually we start with a Paleolithic eating pattern, which only allows for about 80 grams of carbohydrates per day. The Paleolithic diet has been shown to improve insulin sensitivity, blood sugar control, type 2 diabetes, and metabolic syndrome, as well as triglycerides and cholesterol levels. We study this diet in the Wahls lab and have found the Paleolithic Diet to be quite helpful for improving the energy and quality of life for people with MS.
As part of this approach, I have my patients repeat their fasting lipids and blood sugar labs in three to six months to assess their response.
Paleo Diet Overview
To eat: vegetables, fruits, meats, fish, eggs, nuts and seeds
To avoid: added sugars, grains, legumes and dairy
General recommendations:
- Eat more non-starchy vegetables when you can
- Swap out grains for starchy vegetables like potatoes, yams, and squash
- Sub coconut milk for dairy products
- Try to consume a minimum of 0.8 g/kg ideal body weight of protein from meat, fish, and poultry
When Paleo is Not Enough: How to Determine Whether Keto is Right for You
Ketogenic diets have been shown to be helpful for weight loss as well as improving insulin sensitivity, metabolic syndrome, and type 2 diabetes. In one single-arm study of a ketogenic diet, people with MS experienced significant improvement.
Ketogenic diets are high in fat (70–90% of daily calories), moderate in protein, and low in carbohydrates (20–50g/day, depending on which version you’re following).
Instead of burning sugar to power the mitochondria — the “power plants” of your cells — ketogenic diets change the metabolism, so it burns fats or ketones for fuel. When a patient has more severe obesity or type 2 diabetes, and if they are open to trying it, a ketogenic can be very helpful in regressing the diabetes and losing weight.
In these cases, I always make sure that the clinician who is helping the patient manage their diabetes is also agreeable to this approach. I also refer the patient to a Registered Dietitian who can work with them as they begin transitioning from a Paleolithic diet to a ketogenic one, and together we teach them how to monitor their blood ketones.
The goal is to achieve a ketone level of less than 0.4mmol/L. Ketogenic diets should not be done by people who are pregnant, trying to conceive, are breastfeeding, or are very thin.
Family Buy-In and Ongoing Maintenance
Lastly, I will offer the same advice I give to all my patients: try to implement dietary changes as a family. Changing the foods you eat is a difficult undertaking, and it’s even more challenging when members of your household aren’t adhering to the same restrictions and changes.
On the other hand, when the whole family is on board, dietary changes can become something of a bonding experience, a shared goal that can bring you closer as you work together to support the best possible health and quality of life.
Citations
- Ballena-Caicedo J, Zuzunaga-Montoya FE, Loayza-Castro JA, Bustamante-Rodriguez JC, Vasquez Romero LEM, Tapia-Limonchi R, et al. Global prevalence of insulin resistance in the adult population: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2025;16:1646258.
- Giannopapas V, Palaiodimou L, Kitsos D, Papagiannopoulou G, Stavrogianni K, Chasiotis A, et al. The Prevalence of Diabetes Mellitus Type II (DMII) in the Multiple Sclerosis Population: A Systematic Review and Meta-Analysis. J Clin Med. 2023;12(15).
- Yang X, Xu Y, Gao W, Wang L, Zhao X, Liu G, et al. Hyperinsulinemia-induced microglial mitochondrial dynamic and metabolic alterations lead to neuroinflammation in vivo and in vitro. Front Neurosci. 2022;16:1036872.
- Jamka M, Kulczynski B, Juruc A, Gramza-Michalowska A, Stokes CS, Walkowiak J. The Effect of the Paleolithic Diet vs. Healthy Diets on Glucose and Insulin Homeostasis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2020;9(2).
- Manheimer EW, van Zuuren EJ, Fedorowicz Z, Pijl H. Paleolithic nutrition for metabolic syndrome: systematic review and meta-analysis. Am J Clin Nutr. 2015;102(4):922-32.
- Wahls TL, Titcomb TJ, Bisht B, Eyck PT, Rubenstein LM, Carr LJ, 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.
- Zhou C, Wang M, Liang J, He G, Chen N. Ketogenic Diet Benefits to Weight Loss, Glycemic Control, and Lipid Profiles in Overweight Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trails. Int J Environ Res Public Health. 2022;19(16).
- Brenton JN, Lehner-Gulotta D, Woolbright E, Banwell B, Bergqvist AGC, Chen S, 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):637-44.
