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Dr. Terry Wahls is an Institute for Functional Medicine Certified Practitioner and conducts clinical research using functional medicine principles in the setting of multiple sclerosis. In 2018 she was awarded the Institute for Functional Medicine’s Linus Pauling Award for her contributions in research, clinical care, and patient advocacy. Dr. Wahls has secondary progressive multiple sclerosis, which confined her to a tilt-recline wheelchair for four years. Dr. Wahls restored her health using a diet and lifestyle program she designed specifically for her brain and now pedals her bike to work each day. She is the author of The Wahls Protocol: How I Beat Progressive MS Using Paleo Principles and Functional Medicine, The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles (paperback), and the cookbook The Wahls Protocol Cooking for Life: The Revolutionary Modern Paleo Plan to Treat All Chronic Autoimmune Conditions. Learn more about the current study Efficacy of Diet on Quality of Life in Multiple Sclerosis at terrywahls.com/msstudy. Pick up a one-page handout for the Wahls™ Diet. Follow her on Instagram @drterrywahls, and on Facebook/Twitter at @TerryWahls. Sign up to receive her weekly research updates.
Does your doctor tell you food has no impact on multiple sclerosis (MS)? Do they tell you there is no research showing that diet makes a difference for people with MS? They are wrong!
I have been conducting clinical research testing the effects of diet in people with MS for over a decade. The good news is that the tide is finally turning in favor of using diet to help control MS symptoms. Our research lab has investigated the modified Paleolithic diet, ketogenic diet, and the low saturated fat diet.1-7 We have consistently observed that improving diet leads to reductions in fatigue,1,2,6-8 anxiety,4 and depression,4 and improved quality of life.1,2,4,6,7 I have conducted 7 clinical trials and have published over 70 peer-reviewed scientific papers, abstracts, and posters. Our MS diet studies have been cited by other researchers hundreds of times.
More people are doing dietary intervention studies in the setting of MS. There have now been 12 published randomized, controlled, dietary intervention studies in people with MS. There was even a recent editorial in Neurology, the highest impact and most widely read journal that publishes MS research, stating there is now evidence that diet can reduce fatigue and improve quality of life for people with MS. This is huge. If your physicians are telling you that diet does not matter, your physician is not keeping up with the latest research!
We are currently inviting people with relapsing-remitting MS to be in our new study, “Efficacy of Diet on Quality of Life in Multiple Sclerosis.” I will tell you how to sign up for this study later in this article.
Diet studies in MS findings
Regardless of what your physician(s) may say, we now have strong scientific evidence that diet matters.
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 and compares all known studies to identify which treatments are the most effective. This is much stronger evidence than looking at a single study. We now have enough published studies on the role of diet on fatigue and quality of life to conduct these important meta-analyses.
The paper, Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systemic Review and Network Meta-analysis of Randomized Trials,was a network meta-analysis. A network meta-analysis allows the investigator to rank the interventions from most effective to least effective. The paper was published in Neurology, the most widely read journal by neuroscientists and practicing neurologists, in January 2023. Dr. Linda Snetselaar examined randomized dietary intervention studies in MS that lasted at least 12 weeks and had either fatigue or quality of life as an outcome. The authors found 12 studies that investigated 8 diets: Mediterranean, Paleolithic, ketogenic, anti-inflammatory, low saturated fat, fasting, calorie restriction, and control diet (the participant’s usual diet). A total of 608 participants were enrolled in these 12 studies. The standardized mean difference (SMD) was calculated for improvements in measures of fatigue, mental health quality of life, and physical health quality of life for the intervention diets and control diet. The 95% confidence interval (CI) was also calculated for the intervention diet and control diet. If both the SMD improvements and the 95% confidence interval are entirely on the side of the intervention, then scientists can safely state the intervention is effective for reducing fatigue or improving quality of life. That was how Dr. Snetselaar determined whether any of the diets were effective at reducing fatigue or improving quality of life. It is also how she ranked the effectiveness of all 8 diets for reducing fatigue or improving quality of life.
When comparing each dietary intervention to the control diet, three diets had confidence intervals that were entirely on the side of reducing fatigue. The other five diets were not significantly better than the control diet. The magnitude of change for reducing fatigue severity in descending order, was Paleolithic (SMD -1.27; 95% CI -1.81, -0.74), low saturated fat diet (Swank diet) (SMD -0.90; 95% CI -1.39, -0.42), and Mediterranean diet (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 (also known as the Wahls™ diet) (SMD 1.01; 95% CI 0.40, 1.63) and Mediterranean diet (SMD 0.47; 95% CI 0.08, 0.86) diets. All of the Paleolithic diet studies cited in the network meta-analysis and half the low-fat diet (Swank diet) studies were from our lab. Thus the Paleolithic diet that was reported was really the modified Paleolithic diet, also known as the Wahls™ diet.
What diet to follow if you have MS
The three best diets for reducing fatigue and/or improving quality of life are the Mediterranean, modified Paleolithic (Wahls™ diet) and low saturated fat (Swank diet).
The Mediterranean encourages more vegetables and fruits, whole grains, legumes, fish, nuts, and seeds and reduces or eliminates added sugars, processed foods, fast foods, white breads, and white rice. It also reduces dairy and red meat intake.
The low saturated fat (Swank) diet 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, and reduces or eliminates added sugar, processed foods, and fast foods.
The modified Paleolithic diet (Wahls™ diet) encourages more vegetables (target is 6 to 9 servings per day), 6 to 12 ounces of meat or fish per day, and some fermented foods, nuts, and seeds each day. It excludes gluten-containing grains, dairy, and eggs and reduces or eliminates added sugars, processed foods, and fast foods.
Sit down and have a family conversation about this research. Which of these diet plans do you want to try?
Next steps for improving your diet
Processed foods and fast foods are hard to give up. They are everywhere. They are cheap. And they are designed to be incredibly tasty.If you attempt to stop eating processed foods and fast food, you are likely to experience headaches, irritability, and intense cravings. That is because those foods were designed specifically to create food cravings.
I tell my patients that they will be more successful in changing their diet if they implement dietary changes as a family. Talk through which foods you want to eliminate from your diet. Sugar-sweetened beverages and processed snack foods are a terrific place to start. Once you and your family have agreed which food items you want to emphasize and which food items you wish to reduce or eliminate, you can begin to plan for success.
Design your eating environment to support your agreed upon goals. Make it easier to eat the foods you want to encourage and get the food items you wish to reduce or eliminate out of sight to reduce temptation.
It is not easy to stop eating sugar, gluten, dairy, and processed foods. Gluten (protein in wheat, rye, barley, and many ancient grains) and casein (protein in dairy) stimulate the endorphin receptors in the brain, which stimulate the pleasure and attention centers in the brain. As people work to reduce or eliminate sugar and/or processed foods, they may experience cravings and irritability. A great first step is to eliminate sugar-sweetened beverages. Next, look to eliminate the foods that spike blood sugar the most rapidly, which 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).
Again, the modified Paleolithic diet (Wahls™ diet) and Mediterranean diets have many common features, including less added sugar, less ultra-processed foods, and more non-starchy vegetables. The low saturated fat diet also reduces added sugar, ultra-processed foods, and fast foods. Taking out the added sugar, ultra-processed snack foods, and fast foods will be an excellent place to start.
We should not be surprised that the largest effect size seen in the meta-analysis by Dr. Snetselaar was with the modified Paleolithic diet (Wahls™ diet). The modified Paleolithic diet that we have investigated in multiple studies removes the three most common food antigens (gluten, casein, and egg albumin) that cause excessive activation of the immune system.
An editorial entitled The Role of Diet in Multiple Sclerosis: Food for Thought appeared in the same issue of Neurology as Dr. Snetselaar’s network meta-analysis. The authors of the editorial recommended that neurologists talk to all their MS patients about the importance of diet. They said that all MS patients should be told that it is vital to have a healthy diet and that diet influences fatigue and quality of life. They also suggested that MS patients be sent to a Registered Dietitian to receive personalized guidance and support for diet improvement, visits that would likely be covered by many health insurance plans. Finally, they stated that patients should be told that adopting a Paleolithic, Mediterranean, or low saturated fat diets can reduce fatigue and improve quality of life.
We have come a long way. In 2010 my ideas about diet were radical. I was banned as a speaker because my ideas were considered dangerous. The modified Paleolithic diet used to be considered dangerous for MS patients. Now well-respected MS researchers are saying all MS patients should be told to adopt a healthy diet such as Mediterranean, Paleolithic, or low saturated fat diet.
Participate in a research study
This is great progress, but larger, longer diet studies are still needed, which means we need participants, people like you who are willing to be in those studies, who want to help make a difference!
We are currently recruiting participants for a two-year study comparing the modified Paleolithic elimination diet and the time-restricted ketogenic diet to usual diet (NCT05007483). We are looking for people with relapsing-remitting MS between ages 18 and 70. People must be willing to be randomly assigned to either the modified Paleolithic, also known as the Wahls™ diet, the time-restricted olive oil ketogenic diet, or usual diet. You can be following a ketogenic or Paleolithic diet now, but you must be willing to switch to the keto diet or modified Paleolithic diet if randomized to that diet.
You must also be willing to come to Iowa at month 0 for the first study visit. You will also need to return to Iowa at month 3 and month 24. At each assessment, you will complete several questionnaires about mood, energy, and your ability to do the tasks of daily life. You will also do some tests of walking function, hand function, memory, and vision. At month 0 and month 24, you will have a brain MRI (without contrast) to help us measure the rate of brain volume change.
One of the most interesting questions we are asking is whether improving diet will lead to healthier brain aging. People with MS have, on average, a rate of brain volume loss that is 3 times as fast as occurs with healthy aging. That is why people with MS have higher rates of memory problems, early dementia, and walking problems than those who do not have MS. Based on my clinical experience with people who have MS, I expect that we can get people back to healthy rates of brain volume loss when they improve their diets. If our study can demonstrate that, it will be huge, because none of the DMTs have been able to get people with MS back to healthy rates of brain volume loss.
If you have relapsing-remitting MS, are between ages 18 and 70, and are willing to come to Iowa for three visits over two years, we want to include you in this study! If you are interested in participating, complete the screening tool here. Even if you do not qualify for this study, we encourage you to become part of our patient registry. If you have optic neuritis, radiologically isolated syndrome, clinically isolated syndrome, or multiple sclerosis (both relapsing-remitting and progressive MS), I encourage you to complete this short survey and become part of our patient registry.
Changing the standard of care takes 30 years. I am 15 years into this journey–halfway there. It is my goal to have diet become the standard of care, so that everyone who has MS is told that diet matters and is 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, which requires participants willing to do the study intervention and to be the control. Are you ready to participate? To help me change the standard of care?
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 we’ve changed. You can learn more about how you contribute to our innovative research program here.
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. May 2014;20(5):347-55. doi:10.1089/acm.2013.0188
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. doi:10.2147/DNND.S76523
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. doi:10.2147/DNND.S128872
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. Mar-Apr 2017;36(3):150-168. doi:10.1080/07315724.2016.1255160
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. Jan 2021;40(1):13-25. doi:10.1080/07315724.2020.1734988
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. Jul-Sep 2021;7(3):20552173211035399. doi:10.1177/20552173211035399
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. doi:10.2147/DNND.S116949
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. Aug 10 2009;2:7601. doi:10.4076/1757-1626-2-7601