By Tom Garry
Edited by Susan Wells Courtney
Reviewed by Barry A. Hendin, MD
Although more research is needed, studies have shown that diet and nutrition appear to have a significant effect on the progression of multiple sclerosis (MS), as well as on the severity of certain symptoms. Additionally, eating a healthy diet and ensuring good nutrition promotes overall wellness, which is important for everyone – both with and without MS.
In this cover story of The Motivator, top experts provide their thoughts on what foods are best to eat and what foods should be avoided. These experts explain how diet can affect how you feel and provide guidance for improving nutrition. Specifics on certain diets are also included, but please look to our cover story in the next issue of The Motivator for more detailed information on several popular diets, as well as research into how these diets may impact MS and why research has been lacking in the past.
As always, we caution readers not to make any changes to their diet without first consulting a medical professional. The information provided in this article should not be considered as medical advice. We recognize that individuals have their own specific requirements and preferences in terms of diet, and we hope that the details given by the specialists quoted can be of assistance in customizing a diet that not only promotes good health for each individual, but will also provide enjoyment and a better quality of life.
Early Research into Diet and MS
Neurologist Roy Laver Swank, MD, PhD, was a true pioneer in the study of the effects of diet on MS. Driven to learn how diet and nutrition play a role in MS, Roy Swank was able to identify patterns in diet and trends in disease severity. Following World War II, an epidemiological survey he had helped launch showed that for every 10 people diagnosed with multiple sclerosis (MS) in Norway, nine lived in the country’s mountainous inland regions while only one lived along the nation’s extensive coasts.
The neurologist and his colleagues spent time in Europe to gather additional statistics. He noted, “In the mountains, the rural families lived largely on meat, milk, eggs, and cheese, whereas along the coast, people consumed fish and other food sources found in the ocean.”
This conclusion led Dr. Swank to believe that fat was a primary dietary culprit in the development of MS.1 Upon returning to North America, Dr. Swank published his findings in The New England Journal of Medicine in 1952.2 He continued to make diet a primary focus of his research into MS throughout his career, and in 1972, published a book detailing the first diet specifically formulated for people with MS.1
Since Dr. Swank’s pioneering work, many other diets have been evaluated for their potential to ease the symptoms and slow the progression of MS, and at least one other eating plan has been developed specifically to counter the effects of the disease. The author of that approach, Terry Wahls, MD, is a physician and researcher like Dr. Swank, and also is a person living with MS.3
The Wahls Protocol™ diet emphasizes the consumption of vegetables (particularly leafy greens), berries and other brightly colored fruits, meat and fish, and omega-3 fatty acids and other fats from animals and plants. By contrast, people following this diet steer clear of sugar; dairy products and eggs; “nightshade” vegetables, such as tomatoes, peppers, potatoes, and eggplant; legumes, which include beans, peas, peanuts, and more; plus grains, such as wheat and rice.
The breadth of diets being investigated is matched by the depth of people’s interest in the topic. When neurologists J. Nicholas Brenton, MD, and Myla D. Goldman, MD, MSc, surveyed 199 people with MS in 2015, 91.5% of respondents said they were interested in using diet modification as a way to address their MS, and 85% said they were willing to stick with diet therapy for three months or more.4
That desire to enlist diet in the fight against MS is supported by a wealth of encouraging evidence. (Additional studies will be cited in the next edition of The Motivator.)
For example, in 2018, a group of researchers in the United States and Canada constructed a “diet quality score” based on people’s intake of four types of foods: 1. Fruits, vegetables, and legumes; 2. Whole grains; 3. Sugar obtained from sweetened beverages and desserts; and, 4. Red meats and processed meat. They then surveyed almost 7,000 people with MS on their eating habits and assigned each person a diet quality score. They found that people who ranked in the top fifth of the group for diet quality had lower levels of disability and depression than their counterparts who had lower scores, representing a lower-quality diet. The researchers also found that study participants who had a healthier lifestyle overall – one in which a high-quality diet was combined with a healthy weight, regular physical activity, and not smoking – were about one-third less likely than other people studied to report severe fatigue or cognitive impairment, and only about half as likely to report depression or pain.5
In a separate study, a team of Australian investigators monitored almost 1,000 people with MS over 7.5 years and found that those who followed a better diet (in general, think less meat and dairy, more fruits and vegetables) had a better quality of life in terms of physical symptoms than their peers who had a lower-quality diet. Meanwhile, meat consumption was associated with lower physical quality of life, and dairy consumption with lower physical and mental quality of life.6
Despite that evidence, only 17% of the people with MS surveyed by Dr. Brenton and Dr. Goldman in 2015 reported that they were attempting to use diet to impact their MS.4 Why such a low proportion? First, it’s important to note that the question asked about what the study participants were doing when they answered the survey, rather than about past attempts or future plans. Looking at the larger picture, however, if people with MS are uncertain about which diet is the best one for them to follow, it may be because many MS clinicians are, too.
Advocates of various eating plans and researchers assessing those plans tend to agree on two things:
- Avoid processed foods as much as possible
- Eat plenty of fruits and vegetables, although some diet plans carry important caveats about which types of vegetables to eat
Experts say that beyond these two major points, theories on diet are not likely to come together until further research has provided definitive guidance. They add, however, that this is not reason to despair, because there are plenty of steps people with MS can take right now to improve their health by making thoughtful choices about what they eat.
Adopting Practical Approaches while Awaiting Precise Answers
As a young neurologist, Ilana Katz Sand, MD, found that her patients were frustrated – and so was she.
“They would say, ‘I know you want me to take this medication for my MS, and I’ll do that, but what else can I do? What foods should I be eating, or not eating? What diet should I be following?’ And it was very unsatisfying to me as their clinician and as a scientist, and very unsatisfying to them as people who wanted to take a proactive approach to their health, for me to have to tell them that I didn’t have good, evidence-based answers to their questions,” Dr. Katz Sand says of frequent conversations she had with newly diagnosed patients during her fellowship training in multiple sclerosis.
In the 10 years since she completed her MS fellowship, Dr. Katz Sand has devoted much of her time to pursuing those answers through rigorously constructed and conducted studies. Now an associate professor of neurology at the Icahn School of Medicine at Mount Sinai in New York City and a clinician at Mount Sinai’s Corinne Goldsmith Dickinson Center for MS, Dr. Katz Sand has emerged as a leading researcher on the impact of diet on MS disease progression and symptoms. Working with Mount Sinai colleagues and with physicians at other academic medical centers across the country, she has published many papers on the biological mechanisms by which nutrition influences the course of MS. In these writings, Dr. Katz Sand explains how various approaches to eating appear to affect the symptoms often faced by people with MS, including fatigue and cognitive issues, as well as other symptoms.
Dr. Katz Sand says that much has changed for the better over that decade. Researchers know more about diet and MS than ever before, and intriguing findings from small studies and observational analyses are being put to the test in larger, prospective trials. There is also a growing realization that medical students and residents need more training in nutrition, and a greater emphasis on taking a holistic approach to the care of people with MS. One thing, however, hasn’t changed: “Patients still want to know ‘the big secret’ when it comes to diet,” the neurologist says with a smile.
The big secret to diet in MS, according to Dr. Katz Sand and other experts interviewed for this article, is that there is no big secret. Nor, they say, is there definitive evidence supporting a one-approach-fits-all diet or other nutritional remedy for combating the effects of multiple sclerosis.
A registered dietitian nutritionist, Mona Bostick, RDN, LDN, MSCS, explains, “When people with MS see me for a consultation, they often want to know how many blueberries they should eat each day for anti-inflammatory purposes or how much salmon they need to consume to reduce their spasticity.”
She continues, “A lot of my initial work with these individuals is to explain that there has been no research demonstrating that your nutritional needs change when you receive a diagnosis of multiple sclerosis. People with MS do not absorb, metabolize, or excrete the food they eat any differently than other people. So, when people ask about specific foods and the quantities they should eat to have a specific impact on their MS, I tell them that we just don’t have the evidence we would need to endorse such precise steps. We are not anywhere close to that point.” While we await such answers, Ms. Bostick and other experts say, people with MS can benefit from taking five steps. [Please see next section on these “five ingredients.”]
Recommended Dietary Intake: Start with These Five Ingredients
1. Take your nutritional advice (but not your meals) with a grain of salt.
An August 2023 internet search of the term “Diet and MS” yielded roughly 843,000,000 results. The problem, says Ms. Bostick, is that many of those “hits” are actually “misses.”
“People with MS are being bombarded with nonsense. I would say that three-quarters of the questions I’m asked are based on misinformation that people have read on the internet, often from sources that are trying to sell them something,” she explains. Ms. Bostick, who began her nutrition career working with cancer patients in an acute-care, inpatient setting, launched the MSBites website in large part to counter the abundance of questionable or just plain wrong information about multiple sclerosis that she found on the internet after she was diagnosed with relapsing-remitting MS in 2008. “I wish I had a megaphone that I could use to tell people: Talk with your clinician, talk with other healthcare professionals, but don’t listen to Dr. Google!” she says.
Barry Hendin, MD, adds, “Beware fads. Beware anecdotes. Beware highly specific advice that makes highly specific claims.” Dr. Hendin, a Phoenix-based neurologist and MS specialist who serves as the Multiple Sclerosis Association of America’s Chief Medical Officer, says, “The broad outlines of healthy nutritional practices are known to us. Further, several recent studies have yielded encouraging results, and research under way now is going to provide us with great insights in the years ahead. But we’re just not at a stage where we can say definitively that Diet X or Food Y will have Z Effect on multiple sclerosis.”
2. Take out your insurance card and turn it over.
So where can people with MS find reliable information on nutrition? Ms. Bostick recommends that they start by reaching for their wallet instead of their laptop mouse. She doesn’t want them to extract a credit card or cash to buy anything, however. Rather, she says, “Pull out your insurance card and find the number on the back that you can call to learn what benefits your plan offers. Find out if you’re eligible for a certain number of visits with a registered dietitian each year or at least for an initial consultation. If so, take advantage of that healthcare professional’s expertise.” Other resources are available that are free of charge – including reputable websites such as the US Department of Agriculture’s (USDA) website on nutrition at nutrition.gov. A good place to start is by going to nutrition.gov/topics/basic-nutrition.
3. Take a look at what’s realistic – over the long term and for everyday living.
Dr. Hendin explains, “When patients ask me what diet they should follow, I start by telling them that there’s no single magic diet for MS. I then explain that whatever approach they choose should be well-balanced in terms of different types of healthy foods and should be relatively flexible. It should not be so restrictive that you can’t follow it over time.” Dr. Hendin adds, “My view is that eating should provide pleasure as well as nutrition. If a diet turns eating into a chore, you won’t stick with that diet.”
Ms. Bostick has a similar outlook, as she describes on her website. “As a general rule, I opt out of food fights and nutrition extremes or ‘diets.’ I believe that the way to optimal nutrition is through personalized, sustainable habit changes rather than strict, inflexible, and perhaps unrealistic dogma.” In a recent interview, she noted that people can sometimes feel a sense of guilt or shame when they’re unable to adhere to a very restrictive diet, and may even believe that this somehow makes them responsible for their MS getting worse because of a lack of discipline or willpower. The sad irony, she adds, is that those negative emotions are induced by an inability to stay on a very demanding diet that has no foundation in the evidence.
Dr. Katz Sand notes that it’s easier to eat poorly than it is to eat well, not only for people with MS but for everyone. “We’re all so pressed for time that it’s very tempting to just order take-out food, but the more we can make the effort to prepare our own meals, including healthy ingredients and avoiding things like added sugars, the better off we’ll be.”
One of the main ways registered dietitians can assist people with MS, Ms. Bostick notes, is by helping them identify obstacles to good nutritional practices and strategies for overcoming those obstacles. “Based on the available evidence, the principles of healthy eating are not different for people with MS than they are for other people, but healthy eating can be more difficult for people with MS than for others.” This is because of issues with manual dexterity, swallowing difficulties, mobility, vision problems, cognitive issues, and other common manifestations of MS.
“Help the dietitian help you” by providing a complete, honest explanation of your abilities, challenges, preferences, and concerns, so that the dietitian can devise a personalized approach to meal planning and preparation that will work day-in and day-out, Ms. Bostick adds.
4. Take your eyes off the scale, at least at first.
“In counseling patients about diet, I used to focus on weight more than on healthy eating. Then my daughter counseled me,” Dr. Hendin says. He explains that he has three daughters, the oldest a psychologist, the middle one a neurologist, and the youngest a psychiatrist. It was that oldest daughter who convinced him that a change of emphasis was in order. Drawing on her knowledge of human behavior and motivation, she explained that having people concentrate on healthy habits gained rather than excess pounds lost was the better way to promote enduring change.
5. Take a step back to see the larger picture.
“I still encourage people to reach and maintain a healthy weight, but that’s not where I start. I begin by talking about healthy eating and encouraging the adoption of good habits. If people can do that, the weight loss generally will follow,” Dr. Hendin says.
In a similar vein, Ms. Bostick focuses on having people add healthy foods to their diets more than she does on placing restrictions on other foods. The idea, she explains, is to have people feel good about the positive steps they’re taking, rather than feeling badly about not immediately eliminating less-advisable (but often more desirable) items from their diets.
Dr. Hendin says that just as a healthy diet consists of many nutritious foods, a comprehensive approach to healthy living entails much more than eating well. He explains, “Diet has to be part of a larger effort to optimize health, one that includes regular exercise, obtaining sufficient sleep, and maintaining social connections, among other things.” Dr. Hendin adds that just as people with MS should not become overly focused on eating a particular food or losing a specific number of pounds, neither should they let their attention to diet detract from attending to other aspects of their well-being.
What Should People with MS be Eating, and Not Eating, and Why?
Outlining dietary principles and practices, such as those already noted, is all well and good, but it can leave people hungry for something more substantial in terms of which foods they should eat and which they should avoid. While the experts interviewed for this article did not endorse one diet over others for all people with MS, they did have recommendations about healthy eating.
Dr. Katz Sand says, “If there’s one piece of advice I would ask people to follow, it is to try to limit your reliance on processed foods, because so many things flow from that in terms of overall health. Limiting processed foods can be hard. It requires thought and time and preparation, so there’s a lot that goes into it, but the dietary research shows there are significant benefits.” One key to reducing processed foods in your diet is to work with a dietitian or other professional who can “walk through” your day or week with you and devise workable approaches, Dr. Katz Sand adds.
And while we’re on the subject of foods to avoid, what about gluten? (Gluten includes wheat, barley, and rye.) “I think the biggest myth or misperception that I hear from patients is that we’ve determined that gluten is bad for people with MS. We definitely have not demonstrated that through any reliable research, despite what a number of websites may say to the contrary.” Dr. Katz Sand clarifies that she’s not endorsing gluten intake for MS, but rather is highlighting the lack of evidence to support the bad reputation gluten has received in many corners of the internet.
Dr. Katz Sand says that another misperception she frequently encounters is the idea that the more restrictive or inflexible a diet is, the better it must be for you. Not true, she says, noting that variety, balance, and flexibility tend to be the keys to eating plans that are both beneficial and sustainable over time. She also cautions people against the notion that more expensive means more beneficial. “The frozen vegetables in the freezer aisle of your supermarket are a great alternative to fresh produce in the specialty food store,” she says. In addition to their affordability, frozen vegetables are more convenient to store and often easier to prepare, if experiencing challenges such as fatigue, weakness, and reduced manual dexterity.
With regard to the foods that people with MS should be eating, Dr. Hendin provides this advice. “I tell my patients to eat lots of fruits and vegetables. I advise them to eat more chicken and fish and less red meat and processed meats. I tell them to eat more nuts and legumes, and to avoid processed foods.”
If that advice sounds like it could be coming from a cardiologist, there’s good reason for that. Dr. Katz Sand explains, “We’ve seen in observational studies that people with MS who have certain other health conditions have a worse outlook for their multiple sclerosis compared to people who have MS but who don’t have those comorbid conditions.
Dr. Katz Sand continues, “In particular, high blood pressure, high cholesterol, and diabetes confer a worse prognosis for MS. But we don’t have a great understanding yet of why that is. It’s hard to know if, on a pathological basis, there is something that is very specific to MS that is happening, or whether the same biological process is at work and it is just manifesting in people with MS in a way that’s slightly different than in the general population. We have to get the research done so we can give people better guidance in this area.”
Until then, says Ms. Bostick, “Eat with those comorbidities in mind.” She notes that the evidence base for diet and heart disease is much deeper and broader than the evidence available right now on diet and MS, and that the dietary approach outlined earlier by Dr. Hendin has been shown to be beneficial in avoiding or controlling the cardiometabolic conditions linked to worse outcomes in MS.
Dr. Hendin goes a step further. “Although I don’t endorse any one diet, I tend to like the Mediterranean diet, which emphasizes the vegetables, fruits, fish, nuts, and other foods that I recommend, along with whole grains and olive oil. We know, from extensive research, that the Mediterranean diet reduces cardiovascular risk and improves general health, and we think, from early and continuing research, that it also improves MS symptoms. Actually, many of the diets that are of interest to people with MS right now, such as the Mediterranean diet or the Wahls Protocol, emphasize a lot of these foods, although each eating plan differs in important ways,” he says.
Dr. Hendin adds that while studies still need to establish the full benefits and potential drawbacks of specific diets in MS, the weight of the evidence supporting the advantages of healthy eating has changed the way he counsels patients. “I used to say that adopting healthy eating patterns would improve their prognosis over the long term, 10 or 20 years down the line. I still tell patients that, but now I’ve seen enough data to tell them that good nutrition also will help them feel better now, in terms of fatigue and other conditions.”
Ms. Bostick says that short-term improvements experienced by people typically have less to do with adding or excluding a particular food than with enhancing their overall nutritional status. “Someone with MS will come to me and say, ‘I’m experiencing a lot of fatigue, what food should I eat?’ The first thing I look at in such cases is whether the person is meeting his or her nutrient needs. This may sound like a strange thing to say when we’re in the midst of an obesity crisis, but we need to institute malnutrition risk screening for people with MS as part of their regular outpatient care.”
She explains, “While we await further answers on diet and MS, I would encourage people with MS to follow the approaches detailed in the “Dietary Guidelines for Americans” produced by the United States Department of Health and Human Services and available at health.gov/our-work/nutrition-physical-activity/dietary-guidelines. The document emphasizes nutrient-dense foods, a colorful variety of plant-based foods, and other choices that have been shown to be beneficial for all people.”
Ms. Bostick concludes, “Eating is a really important component of health for every person, and when you have a chronic condition such as MS, it becomes even more important. As both a dietitian and a person living with MS, I understand the desire for very specific answers, very precise guidance. But that guidance has to be reliable and well-validated. We’re moving in that direction, but until we’re there, I want people with MS to know that they don’t need to wait to enhance their well-being – there are sound, sensible things they can do right here and right now to improve their overall health.”
1 Swank MS Foundation. Swank MS Foundation: For Your Health, For Your Future. Available at swankmsdiet.org. Accessed August 13, 2023.
2 Swank RL, Lerstad O, Strom A, Becker J. Multiple sclerosis in rural Norway – its geographic and occupational incidence in relation to nutrition. N Engl J Med. 1952;246:721-728. DOI: 10.1056/NEJM195205082461901.
3 TerryWahls.com. My Story. Available at https://terrywahls.com/about/about-terry-wahls/. Accessed August 15, 2023.
4 Brenton JN, Goldman MD. A study of dietary modification: perceptions and attitude of patients with multiple sclerosis. Mult Scler Relat Disord. 2016;8:54-57.
5 Fitzgerald KC, Tyry T, Salter A, et al. Diet quality is associated with disability and symptom severity in multiple sclerosis. Neurology. 2018;90e1-11. doi:10.1212/WNL.0000000000004768.
6 Simpson-Yap S, Nag N, Probst Y, Reece JC, Jelinkek GA. Mult Scler Relat Disord. 2022;60.doi:10/1016/jmsard2022.10371.