Food Matters for Improving Your Energy and Your Mood and Research Opportunity

Is your neurologist asking about your diet?

The evidence continues to grow that the food we eat can either lead to more energy or more fatigue for those with multiple sclerosis (MS). It can also lead to less anxiety and or depression and better quality of life. Disease modifying drug treatments have been shown to reduce the number of new enhancing lesions and the reduced the risk of relapse. But research is showing that diet can be a helpful adjunct to reducing MS-related symptoms. Is your medical team helping you improve your nutrition?

I have been conducting clinical research testing the effects of diet in people with MS since 2010. Our studies have included the modified Paleolithic diet, ketogenic diet, and the low saturated fat diet ^1-7. We have consistently observed that following one of these diets leads to reductions in fatigue ^{1, 2, 6-8}, anxiety ^{4, 9}, depression ^{4, 9}, and improved quality of life ^{1, 2, 4, 6, 7}.

We have a new study for people with relapsing-remitting MS: Efficacy of Diet on Quality of Life in Multiple Sclerosis. In this study, we help people improve their nutrition to investigate the impact of diet on fatigue and quality of life. We’d love to include you in this study! I will have more details about how to sign up for this study later in this article.

Diet studies in MS findings

Each year there is more published research about the effect of diet on fatigue and quality of life in MS. The strongest evidence that an intervention is helpful (or harmful) is when multiple studies are combined and analyzed together. This type of analysis is called a meta-analysis. A network meta-analysis combines all known studies and compares them to identify 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.

One paper, Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systemic Review and Network Meta-analysis of Randomized Trials, was published in Neurology, the most widely read journal by neuroscientists and practicing neurologists, in January 2023 [10]. Dr. Linda Snetselaar conducted a network meta-analysis of randomized dietary intervention studies in MS that lasted at least 4 weeks and had either fatigue or quality of life as an outcome. Dr. Snetselaar and her team found 12 dietary intervention studies investigating Mediterranean, Paleolithic, ketogenic, anti-inflammatory, low-fat, fasting, calorie restriction, and control diet (the participant’s usual diet). A total of 608 participants were enrolled across all 12 studies. The standardized mean difference (SMD) was used to compare the improvements in fatigue and quality of life. The 95% confidence interval (CI) was also calculated for the intervention diet and the control diet. If the improvements and the 95% CI are entirely on the side of the intervention, then one can safely state the intervention is effective for reducing fatigue or improving quality of life.

When comparing each dietary intervention to control diet, three diets had confidence intervals entirely on the side of reducing fatigue. 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 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.

What diet to follow if you have MS

The key elements for 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

Modified Paleolithic

• 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.

Next steps for improving your diet

I encourage my patients to make diet changes as a family. Decide as a family which foods you will emphasize and which food items you wish to reduce or eliminate. Consider taking a cooking class to acquire more cooking skills. It is not easy to stop eating sugar, gluten, dairy, or processed foods. Gluten (the protein in wheat, rye, barley, and many ancient grains) and casein (the protein in dairy) stimulate the endorphin and opioid receptors in the brain. That is why stopping gluten and casein can be very difficult. Reducing sugar is likewise very difficult.

In the first week, people often experience cravings and irritability if they reduce or eliminate those foods. A great first step is to eliminate sugar sweetened beverages. Next, look to eliminate foods that spike blood sugar the most rapidly. These are white bread, pasta, cereal and whipped white potatoes. Third, reduce or eliminate fast foods. Those initial steps are all part of the recommendations for the three most effective diets (Mediterranean, modified Paleolithic, and low saturated fat).

A Neurology editorial, The Role of Diet in Multiple Sclerosis: Food for Thought ¹¹, appeared in the same issue as Dr. Snetselaar’s meta-analysis. The authors of the editorial recommend that neurologists talk to their MS patients about the importance of diet. They state that all MS patients should be told that diet influences fatigue and quality of life. Neurologists could send their MS patients to registered dietitians for guidance and support in improving their diet, which would likely be covered by many health insurance plans. The editorial authors also note that the research shows that Paleolithic, Mediterranean, and low-fat diets can reduce fatigue. Now well-respected MS researchers are saying all MS patients should be counselled about adopting a healthy diet such as Mediterranean, Paleolithic, or low saturated fat diet.

Participate in a research study

Larger, longer diet studies are needed. And we need people who are willing to be in those studies. We are currently conducting our eighth clinical trial, a two-year study comparing the modified Paleolithic elimination diet and the time-restricted ketogenic diet to usual diet (control) (NCT05007483). We are looking for people with relapsing-remitting MS between ages 18 and 70 who live in the United Stated, Canada, or Mexico. Learn more about the study here. People must be willing to be randomized to one of three diets: the modified Paleolithic, also known as the Wahls™ diet, the time-restricted olive oil ketogenic diet, or usual diet. Screen to see if you are eligible for the study here.

Even if you do not qualify for this study, we encourage you become part of our participant registry. If you have optic neuritis, radiologically isolated syndrome, clinically isolated syndrome or MS (both relapsing-remitting and progressive MS), I encourage to complete this short survey and become part of our registry so we can inform you about future studies.

I tell my students and postdoctoral research scholars that changing the standard of care takes 30 years. I am 15 years into this journey. It is my goal to have it become the standard of care that everyone who has MS is told that diet matters and is encouraged to improve their diet to both improve their lives today and better manage their disease course. 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! Let’s change the world together!

Citations

1. Bisht, B., et al., A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med, 2014. 20(5): p. 347-55.

2. Bisht, B., 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: p. 19-35.

3. Bisht, B., 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: p. 79-93.

4.  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.

5. 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.

6. 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.

7. Irish, A.K., et al., 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: p. 1-18.

8. Reese, D., et al., 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: p. 7601.

9. Shemirani, F., et al., Association of serum homocysteine, folate, and vitamin B(12) and mood following the Swank and Wahls elimination dietary interventions in relapsing-remitting multiple sclerosis: Secondary analysis of the WAVES trial. Mult Scler Relat Disord, 2023. 75: p. 104743.

10. Snetselaar, L.G., 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): p. e357-e366.

11. Spain, R.I., L. Piccio, and A.M. Langer-Gould, The Role of Diet in Multiple Sclerosis: Food for Thought. Neurology, 2023. 100(4): p. 167-168.