In this article, I'll share my comprehensive approach to working with multiple sclerosis (MS) patients. You'll learn about disease-modifying treatments (DMTs), evidence-based nutritional strategies, and the dietary patterns that have shown the most promise for improving quality of life. I'll also cover the basic supplements I recommend to support brain health and overall wellness.
DMTs vs. Nutritional Changes: You Don’t Have to Choose
One of the most common questions I hear is whether patients should take a disease-modifying treatment or focus on improving their nutrition instead. The answer is simple: you don't have to choose. You can (and should) do both.
The decision about whether to start a DMT will depend on several factors: the risks of immune suppression; the potential harm from ongoing inflammation in your central nervous system (brain, spinal cord, and cranial nerves); and the possibility of rare but serious side effects.
Here's what I tell my patients—it's crucial to stop new lesions from forming and prevent ongoing relapses. You can absolutely start a DMT to quiet disease activity while simultaneously optimizing your nutrition and other lifestyle factors. DMTs are very effective at suppressing immune system activity and reducing both new enhancing lesions and relapses.
For patients with active disease (new enhancing lesions on MRI or recent relapses) I do encourage starting a potent DMT. However, if you haven't had new enhancing lesions, relapses in the past year, or any fixed disability, it may be reasonable to focus on optimizing your environment and other modifiable lifestyle factors before adding a DMT.
To be clear, this isn't an either/or decision. I want all of my patients to focus on comprehensive self-care—optimizing nutrition, exercise, sleep, and stress management—while also having thoughtful conversations with their neurologist about the benefits and risks of DMTs. Regular brain MRI scans are also important for monitoring your condition.
Your neurologist likely doesn't have the time or expertise to work with you around the specifics and nuances of improving your self-care. In these next few sections, we’ll look at some practical suggestions to get you started.
Better Nutrition: The First Steps
The standard American diet relies heavily on ultra-processed foods. In the U.S., children get about 70% of their calories from added sugar and white flour, while adults get about 60% from these sources.[1]
During processing, white sugar and flour are stripped of their natural vitamins and minerals, which can contribute to B vitamin and mineral deficiencies. Many Americans also don't get adequate amounts of magnesium, zinc, and other essential vitamins—deficiencies that may contribute to chronic diseases affecting the brain.[2]
Talk to Your Family, and Start Small
Talk with your family about what dietary changes you might be able to make together. People with support systems at home tend to be more successful at maintaining nutritional changes long-term.
Additions are easier than subtractions, so I recommend starting there. Focus on what you can add to your diet rather than what you need to eliminate. Some simple food swaps that can improve your family's nutrition include:
- Replacing sugar-sweetened beverages with water or herbal teas
- Swapping white flour-based bread, pasta, and cereal for starchy vegetables like potatoes, sweet potatoes, and squashes
Once you've mastered these basic changes, you can consider trying one of the specific dietary approaches that have been shown to improve outcomes for people with MS.
Dietary Approaches That Can Help People with MS
When you're ready to explore a more targeted nutritional strategy, there are several dietary approaches that have shown promise for reducing fatigue and improving quality of life in people with MS. Here's what the research tells us about each approach, along with practical considerations for implementation.
Paleolithic (Paleo) Diet:
Eliminates added sugar and flour-based bread, cereal, and pasta, as well as most grains. Emphasizes meat, fish, vegetables, and berries.
- Research findings: Shows the largest effect size for improving both quality of life and reducing fatigue in people with MS.[4-6]
- Wahls approach: The modified Paleolithic diet we study in the Wahls laboratory also eliminates dairy and eggs.
Mediterranean Diet:
Reduces or eliminates added sugar, white flour-based bread, cereal and pasta, and red meat.
Emphasizes fish, legumes, vegetables, and berries.
- Research findings: Second most effective for reducing fatigue and improving quality of life.[4-6]
- Wahls approach: The modified Mediterranean diet we use also eliminates dairy.
Practical considerations: Less restrictive than Paleolithic or ketogenic approaches, which may make it easier to transition from a standard American diet.
Low Saturated Fat Diet:
Reduces or eliminates red meat, eggs, and other saturated fats.
Encourages white fish, white poultry meats, and vegetables.
- Research findings: Effective for reducing fatigue (third most effective, after Paleo and Mediterranean diets).[4-6]
Ketogenic Diet:
Reduces or eliminates added sugar, flour-based foods, starchy vegetables, and fruit. Fat provides 70-90% of daily calories, with total carbohydrates limited to less than 35 grams per day.
- Research findings: May be less helpful overall than other approaches, but it can be beneficial for specific conditions.[3]
- Best suited for: People with insulin resistance, fatty liver disease, pre-diabetes, or diabetes, as it can improve insulin sensitivity and mitochondrial efficiency.[3]
- Wahls approach: The version we study emphasizes olive oil as the primary fat source.
- Important considerations: Often emphasizes eggs and dairy, which may be inflammatory for some people. It can also be relatively difficult to adhere to this diet long-term. If you try it, work closely with your medical team to monitor fasting lipid profiles.
Intermittent Fasting (5:2 Plan):
Restricts calories to 25% of usual intake (300-500 calories) two days per week, while maintaining normal intake the other five days. Not gluten-free or dairy-free.
- Research findings: Less helpful than dietary pattern changes, but it can improve insulin sensitivity and mitochondrial efficiency.[3]
No matter which approach you choose, it's important to inform your primary care team and specialists about the dietary changes you're making. As your nutrition improves, your blood pressure and blood sugar levels are likely to improve—which means any medications you're taking may need dosage adjustments.
Remember, we've studied several of these approaches in the Wahls laboratory and consistently find that people experience reduced fatigue and improved quality of life as their nutrition improves.[4-6] The key is finding an approach that works for your lifestyle and health needs, and then sticking with it long-term.
How Your Dietary Intake Affects Your Cellular Health
Every second, approximately 2 billion chemical reactions occur within your cells. These reactions depend on enzymes (certain proteins that help speed up chemical processes) along with their vitamin and mineral cofactors (helper molecules that enzymes need to function properly).
This is why ultra-processed foods can be so problematic for cellular health. When vitamins and minerals are stripped away during processing, it disrupts the optimal environment your cells need to function. Without adequate minerals and vitamins, the enzymes responsible for essential life processes can't work efficiently. Over time, this can lead to increased fatigue, lower mood, more pain, and eventually, chronic disease.
Unfortunately, most Americans don't get adequate amounts of the multiple minerals and vitamins that are crucial for immune and metabolic health.[7]
Targeted supplements to support brain health
Your brain has the highest energy demands of any organ and is particularly sensitive to mitochondrial dysfunction. People with MS—especially those with more severe disease—are more likely to have significant nutrient deficiencies compared to people without MS.[8]
The key nutrients for mitochondrial function, brain health, and healthy aging include omega-3 fatty acids (for cell membranes), B vitamins, magnesium, and zinc.[9] Vitamin D and other micronutrient deficiencies have been linked to accelerated aging and worse outcomes across multiple conditions, including MS.[10]
Research shows that taking 1-4 grams of supplemental fish oil daily has been associated with lower relapse rates, improved quality of life, and slower disease progression in people with MS.[11] Based on this evidence, I recommend a basic supplement program for my MS patients that includes:
- Vitamin D3 plus vitamin K2
- Fish oil
- Multivitamin/multimineral
- Magnesium
These targeted supplements can support both brain health and overall longevity for people with MS.[9, 10]
Summary
You don't have to choose between taking a DMT and improving your nutrition; you can and should do both. My goal is to help patients stop new lesions and relapses from developing, which may mean combining a potent DMT with comprehensive nutritional support.
Here are some key takeaways:
- Work steadily to improve your nutrition, and have your primary care team monitor your blood lipids and adjust medications as needed.
- Several dietary approaches have shown benefits for improving quality of life and reducing fatigue in people with MS.
- Make dietary changes as a family when possible, and progress at a pace your family can sustain.
- People with MS are more likely to have nutrient deficiencies than those without MS; targeted supplementation can help address these gaps
The Wahls Protocol® Basic Support kit includes vitamin D3 plus vitamin K2, fish oil, multivitamin/mineral, and magnesium—all important nutrients for supporting brain health and longevity.
Citations
- Silva, L.V., et al., Association of minimally processed and ultra-processed food daily consumption with obesity in overweight adults: a cross-sectional study. Nutr Hosp, 2023. 40(3): p. 534-542.
- Cordain, L., et al., Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr, 2005. 81(2): p. 341-54.
- Wahls, T.L., 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): p. 20552173211035399.
- Lee, J.E., et al., 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): p. 13-25.
- Lee, J.E., et al., A Multimodal, Nonpharmacologic Intervention Improves Mood and Cognitive Function in People with Multiple Sclerosis. J Am Coll Nutr, 2017. 36(3): p. 150-168.
- Paoli, A., et al., Common and divergent molecular mechanisms of fasting and ketogenic diets. Trends Endocrinol Metab, 2024. 35(2): p. 125-141.
- Reider, C.A., et al., Inadequacy of Immune Health Nutrients: Intakes in US Adults, the 2005-2016 NHANES. Nutrients, 2020. 12(6).
- Armon-Omer, A., et al., New Insights on the Nutrition Status and Antioxidant Capacity in Multiple Sclerosis Patients. Nutrients, 2019. 11(2).
- Ames, B.N., Prolonging healthy aging: Longevity vitamins and proteins. Proc Natl Acad Sci U S A, 2018. 115(43): p. 10836-10844.
- Ames, B.N., Musings in the twilight of my career. Free Radic Biol Med, 2022. 178: p. 219-225.
- AlAmmar, W.A., et al., Effect of omega-3 fatty acids and fish oil supplementation on multiple sclerosis: a systematic review. Nutr Neurosci, 2021. 24(7): p. 569-579.
