#DietSpeak: is there an ideal MS diet?

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Barts-MS rose-tinted-odometer: ★★★★★

I am always being asked about what is the ideal diet for someone with MS. The simple answer is there is no ideal MS diet. What you eat is about personal choices and has to be compatible with your cultural background and your social circumstances. There is so much more to eating food than what you actually eat. I have written a piece on Medium called ‘Diet as a Philosophy’, which provides some context to this statement. 

In short, my diet philosophy recommends that anyone with MS should eat socially, i.e try not to eat alone and make your meals a social occasion. To eat real food, i.e. avoid processed and ultra-processed food. To try and eat locally-produced food that is seasonal; I am aware that this easier said than done, particularly for economic reasons. Finally, it would help if you eat mindfully, in other words, think about what you are eating, why you are eating it and what impact it is having on the world. 

The question about diet being an actual treatment for MS is a different question. Here I would support a ketogenic diet and intermittent fasting and I have written extensively on the science behind these diets and why I think these two diets may be disease-modifying for people with MS. At present, the evidence base for these diets working in MS remains weak and exploratory, but the good news is there are ongoing studies looking at these diets in pwMS. Despite this, the basic science on these diets from animal studies is so compelling that if I had MS I would be ketotic and fasting intermittently (5:2 or 16:8 diet). 

Please note ketogenic diets and intermittent fasting are not incongruent with my diet philosophy. 

I also don’t support one diet over another. The reason I don’t support a specific diet is simple; the evidence-base for anyone diet being better than another is weak and a lot of diets are not based on science. Yes, science. As scientists, we should be following the science. For example, the study below is interesting in that they flipped the question and looked at the metabolic responses to food and its influence on cardiometabolic disease. You may say what has this got to do with the central nervous system, but I believe in the aphorism ‘that what is good for the heart is good for the brain’.  

What this study showed is that person-specific factors, such as gut microbiome, had a greater influence than the diet in relation to metabolism and that genetic variation only had a modest impact on the metabolic responses to food linked to cardiometabolic disease. The only metabolic output that was influenced by diet was blood glucose or sugar levels, which is dictated by carbohydrate intake and the type or quality of carbohydrates we consume. 

In summary, apart from carbohydrate metabolism, it is horses for courses and personal factors (gut microbiome and genetics) which dominate how your diet impacts on your metabolism. 

The good news is you can manipulate your carbohydrate metabolism; it is relatively simple. Both ketogenic diets and intermittent fasting reduce your sugar intake and blunt or flatten your blood glucose levels and the subsequent downstream insulin response, which is clearly the bad guy in driving cardiovascular risk. 

Based on the above I hope you have enough information at hand for you to make an informed decision about your diet without having to ask me next time 😉

Berry et al. Human postprandial responses to food and potential for precision nutrition. Nat Med 2020 Jun;26(6):964-973. doi: 10.1038/s41591-020-0934-0. Epub 2020 Jun 11.

Metabolic responses to food influence risk of cardiometabolic disease, but large-scale high-resolution studies are lacking. We recruited n = 1,002 twins and unrelated healthy adults in the United Kingdom to the PREDICT 1 study and assessed postprandial metabolic responses in a clinical setting and at home. We observed large inter-individual variability (as measured by the population coefficient of variation (s.d./mean, %)) in postprandial responses of blood triglyceride (103%), glucose (68%) and insulin (59%) following identical meals. Person-specific factors, such as gut microbiome, had a greater influence (7.1% of variance) than did meal macronutrients (3.6%) for postprandial lipemia, but not for postprandial glycemia (6.0% and 15.4%, respectively); genetic variants had a modest impact on predictions (9.5% for glucose, 0.8% for triglyceride, 0.2% for C-peptide). Findings were independently validated in a US cohort (n = 100 people). We developed a machine-learning model that predicted both triglyceride (r = 0.47) and glycemic (r = 0.77) responses to food intake. These findings may be informative for developing personalized diet strategies. The ClinicalTrials.gov registration identifier is NCT03479866.

CoI: multiple

Twitter: @gavinGiovannoni         Medium: @gavin_24211

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

43 comments

  • Wonderful to have these ghosts (gluten, dairy, eggs) laid to rest, and a committed, sensible answer, finally!
    — Now, what about some really effective physiotherapy to improve mobility? I am thinking of hydro therapy, FES cycling, neither of which seem to be available. If one can improve mobility, one can build on it!
    The question is, what can a highly motivated pwms do, in addition to diet?

    • Exercise (physical and mental), sleep hygiene, mindfulness, moderate or no alcohol intake, maintain a healthy weight, be screened for and have your comorbidities treated, stop or reduce you anticholinergic exposure, keep vitamin D replete and be social. The latter may the most important component of wellness, i.e. maintain and if possible expand your social capital.

  • There was an article yesterday in the New York Times questioning the benefita of intermittent fasting. Did you see it? A study showed that fasting results in muscle loss. The man (I forget his name) who has been an advocate for fasting said it was so compelling that he himself has stopped. If you have any thoughts, I would appreciate hearing them. Thank you.

    • I am a 35 year old man who has been intermittent fasting since the lockdown. I personally (so just one data point) have lost weight (mainly fat) as demonstrated by waist reduction. However, since my MS symptoms are rather mild comparatively, I am able to engage in resistance training (pull ups, weighted push ups, etc) which has increased (slightly) my overall muscle mass. I have also made sure to increase my protein intake dramatically. My “meathead” friends who weight lift more than I tell me that any weight loss in general results in muscle mass loss unless you both increase your protein consumption and engage your muscles in significant exercise.

      If we think from an evolutionary perspective, our ancestors would have not have done what we call intermittent fasting without strenuous exercise and a diet consistently of mainly meat and vegetables.

      But what if you have MS and you can’t resistance train? Would the benefits of IF outweigh the costs of loss in muscle mass over the long term?

      • Yes, exercise will provide the necessary stimuli to maintain muscle strength, but not necessarily bulk as some of the muscle bulk is due to fat, which gets deposited in the muscle. The latter is what farmers try to do by reducing their animal’s ability to exercise, by corralling them, and then feeding them with carbohydrate-rich foods, e.g. corn and other grains. The fat is what makes Wagu and Kobi beef taste so nice and causes the marbling of the meat.

    • Muscle loss happens if you caloric restrict. This is why ketogenic diets trump intermittent fasting and caloric restriction; ketogenic diets are not associated with muscle loss. In fact, most bodybuilders are on non-caloric-restricted ketogenic diets; they use them to actually build muscle and to lose fat.

      • Please note I refer to ketogenic diets rather than a ketogenic diet because you can still be selective on what foods you eat to become ketotic. I say this knowing that ketogenic diets are very difficult for vegetarians and particularly difficult for vegans.

  • Fasting wouldn’t be suitable for me as I’m borderline under weight and I also walk around 10 – 15km each day.

    • You can still do intermittent fasting provided you make-up for the lost calorie intake on the days you don’t fast. Intermittent fasting works as a metabolic switch, i.e. it triggers ketogenesis and the so-called NRF-2 pathway and at the same time inhibits the NF-kappa-beta signalling pathway, which is the master regulator of inflammation.

      Interestingly, metformin the diabetes drug and dimethyl fumarate a licensed MS DMT do similar things to IF and physiological ketosis.

  • When I spoke to my neurologist about diet, he suggested to just follow a balanced diet on the basis that part of his role was to help me forget that I had MS and it would not help me to think about each meal, snack etc in the context of this chronic disease. I’m beginning to think this is decent advice. I’ve been practicing dairy and gluten free but when you’re pals are all ordering beer n pizza, and you’re making do with carrot sticks n hummus, its really just a reminder that you’re sick and they are not

    • This is why diets have to be social. Intermittent fasting will allow you to have beer and pizza, just not every day.

      Not sure there is evidence to support a dairy- and gluten-free diet to treat MS. The only indication for being dairy- and gluten-free diets are allergies.

    • Thanks. Are you on a ketogenic diet, intermittent fasting or both? How does it make you feel?

      We need more pwMS who have hacked their biochemistry to speak out about how it makes them feel.

      • I did IF a few times before and once after diagnosis. Did not notice any obvious changes aside of losing weight which I really should not.

        Wary of trying keto for that reason.

        FWIW, I’ve been told by two neuros to eat what basically amounts a balanced Mediterranean aligned diet which I broadly do anyhow.

      • Ok

        Been fasting for almost 4 years now (diagnosed 2016) next february its 5 years since first episode
        In 53 days i will be 3 years hsct anniversary

        I do ,16 hours without food ( no breakfast ,start eating at 13h stop eating at 21h in the evening)
        Monday ,tuesday , wednesday, eat what ever i want

        Thursday i only eat one meal 600 calories all day long

        ,Friday start eating again at 13h eat whatever i want (not to much sugary things

        Saturday same as friday

        Sunday again just one meal 600 cal. all day long

        So 16h hours time window plus 5:2 diet every week

        On the fasting days (thursday and sunday ) if i´m doing normal daily activities i loose 1 to 1,5 kilos

        3 times a year i spend 3 to 4 days without food(prolong fast) just water and tea

        That´´´ s quite hard i loose 3 to 3,5 kilos (blood glucose 50 at the end of the 3 day fast)

        M,s wise since i have starting doing fasting i dont have ms symptoms on the fastings days nad minor on the other days

        Once you past some time threshold (for me its around 18, 19 hour) your mind start to be quite focus and you dont feel hungry as time goes by

        Side efects

        The longer the fast the more cold you get
        In the prolong fasting “craziness”, every night it becames harder and harder to sleep

        When you can sleep you dream about food 🙂

        Your blood cholesterol goes up (especially in prolong fast) ….
        lipolysis i guess???

        Triglycerides goes way down

        Your urine turns brown

        Its important to do the refeeding with easy digestible foods

        Remember:

        Every fool can fast, but only the wise man knows how to break a fast.

        George Bernard Shaw

        For me fasting makes a lot of sense

        Imagine a cell in your body like your living room

        Now imagine that your living room its allways packed will people (party party 24/7)

        Dancing,,eating smoking, jumping , drinking …etc

        You get the picture 🙂

        ..There no cleaning ,no stoping ,no repair

        Our cells must work ,rest , eat , and fast

        And they repair best when you fast

        Obrigado

          • When first time doing fast

            The best way is to stick to whatever fasting regime that work for you, preferably forever 🙂

            You will notice that your body looses weight
            quite fast ,but if you continue the body adapt and your weight stabilizes in a narrow range that for me is around 67 kg +-1kg
            The day after the fasting day, of course you are hunger and you tend to eat a little more to make up for the lost calories ,but that tends to fade out with time as your system will adapt, living without +-3600 calories each week

            Exercise and fasting as manny benefits to your health if i would not be able to exercise at least i would be fasting (i do both
            )
            You would need 6 days a week 1 hour biking to get to 3600 calories lost(burn) in a week in case you dont want to fast

            Fasting its good for you for the planet for your wallet, and for every one with chronic disease

            Fasting, or intermittent fasting, gives us an opportunity to really get all the best cells all the time and that’s what we all want.

            Steven Gundry

  • I’m tired of people preaching about diet. I’m very happy with mine now, but don’t tend to recommend anything to anyone, as every person is so different.

    I’ll listen to and consider what seems to me to be good sense. Just don’t try to tell me I can’t have green tea or make homemade bread.

  • Unfortunately IF is not compatible with DMF. I don’t think it is wise to take DMF on an empty stomach in the morning. I’m sure I will suffer from a flush.

    Or does someone have a recommendation for DMF in combination with IF?

  • To begin with, thank you (and the other professionals who post here) for all that you’re doing. I cringe asking idiotic questions here because I know you are all working so hard. I’d love it if you could be my doctor.
    I already (unintentionally) do a weird version of intermittent fasting. I’m underweight 🙁 MS has really messed with all aspects of my digestion and ability to eat much. It’s kinda suspected that I have some type of gastroparysis, but no one has bothered with further investigation about that.

    I never really even feel hungry. I feel like eating more than a half a cup of anything will make me vomit. Plus (sorry, gross) painful and extreme constipation. I’ve been told to drink the higher calorie Boost and Ensure nutrition drinks. I’ve tried to do that but I can’t stomach them anymore.

    Sorry for that sob story 🙄 I’m desperate for something because I’ve been losing so much ground. Was doing a lot better than I am now thanks to an amazing neuro physical therapist who was working with me in the swimming pool. It was amazing for me. Then came this neverending relapse a few months after my third dose of Ocrevus. I now really regret letting that get pushed on me. I can’t even physically go to physical therapy at this point. Hopefully that gets better?
    Anyway, does anyone think that a keto diet might be possible for me to do without losing anymore weight? At this point I don’t even care if it ends up helping me. If it did, I’d just consider that to be an unexpected bonus :/

    • Re: “… I feel like eating more than a half a cup of anything will make me vomit….”

      This is not a symptom that I would put down to MS. More likely a true or functional gastric outlet obstruction; pyloric stenosis or pyloric spasm come to mind. These are diagnosed by gastroenterologists and treatable conditions.

      • I just read this. 2.neurologists have (kinda?) brushed it off. They think that it’s gastroparysis caused by a lesion on my spinal cord. Apparently, there really isn’t a real treatment for that. I’m going to ask for a referral to a gastroenterologist. I’ve briefly mentioned that before but it didn’t happen. I guess I’ll have to be a little more insistent this time. I’m just sooo tired. I’d love to feel like I’m not fighting an unwinnable battle.

  • Why are Swank’s longitudinal observations, and the OMS evidence that builds on them, not compelling about the efficacy of a diet low in saturated fat?

  • ‘The best way is to stick to whatever fasting regime that work for you, preferably forever 🙂’
    Luis today 12.03am.

    I agree with Luis and with the expert opinions of Mark Mattson, John Hopkins Medicine neuroscientist.
    He says: an array of animal studies and some human studies have shown that alternating between times of eating and fasting supports cellular health, improves blood sugar regulation, resistance to stress, and suppresses inflammation. He also says that preliminary studies, such as the University of Toronto clinical trial, suggest IF could benefit brain health too. Mattson doesn’t agree with Longo that diets such as the 5:2 don’t last long enough to achieve the switch to ketosis and is quite happy to support this and the 16:8 approach.

    I have been using 16:8 for about three years now and like Luis consume calories, both drinks and food, between 1pm and 9pm. Though, my consumption around 8pm is a very (un)healthy small amount of chocolate with a hot drink. I had to work up to 1pm by pushing breakfast later and later, but now don’t even notice it anymore. As Luis says – no sense of hunger at all!

    Added to which, I exercise at the gym a couple of times a week, in the mornings. Although my MS means that I can no longer run or even jog slowly, I can walk 3km on a treadmill (around 34mins for me) and am not aware that I’ve an empty stomach.

    I think one of the advantages of the 16:8 approach is that it’s very easy to be flexible. As ProfG says there are social and cultural elements to diet, so if friends want to meet up for brunch or the Christmas meal is at 3pm I can simply re-gig the hours I’m working to.

    Whilst a more recent study has raised the concern of loss of muscle mass with IF, it does seem to me to be of sufficient benefit if, like me, you find you’re comfy with this style of engaging with food and drink consumption.

    • Thanks

      Yoshinori Ohsumi of Japan Wins Nobel Prize for Study of ‘Self-Eating’ Cells

      Yoshinori Ohsumi, a Japanese cell biologist, was awarded the Nobel Prize in Physiology or Medicine on Monday for his discoveries on how cells recycle their content, a process known as autophagy, a Greek term for “self-eating.”

      It is a crucial process. During starvation, cells break down proteins and nonessential components and reuse them for energy. Cells also use autophagy to destroy invading viruses and bacteria, sending them off for recycling. And cells use autophagy to get rid of damaged structures. The process is thought to go awry in cancer, infectious diseases, immunological diseases and neurodegenerative disorders. Disruptions in autophagy are also thought to play a role in aging.

      But little was known about how autophagy happens, what genes were involved, or its role in disease and normal development until Dr. Ohsumi began studying the process in baker’s yeast

      https://www.nytimes.com/2016/10/04/science/yoshinori-ohsumi-nobel-prize-medicine.html

  • Hi, Can you please clarify a bit more on what you mean by “ketogenic diets rather than a ketogenic diet”.
    I’ve had MS for ten years and changed my diet about three years ago to a more low fat one.
    Not opposed to giving keto a try though.

  • Prof G, If you’ll allow me to share a discussion I had with a ‘newbie’ in my MS facebook group … I’m feeling rather proud of myself … this took place a week before the blog!
    “Hey Bron I’d be interested to know if you follow the OMS plan or have tried it?”
    I replied
    “Greg,that’s a great question!
    The first thing to consider is our individual genes and individual gut microbiomes are all unique.
    Also no one ‘regime’ purports to offer a cure.

    That said, everyone with MS wants to continue to hope.

    My ultimate recommendation is to eat healthily and avoid processed foods. There is little proof on anything else being of benefit.

    However I have followed the diet element of OMS. Did it for 12 months. I’ve felt better.

    I also followed the Wahls protocol for 12 months. Certain elements I have continued with (heaps of veg especially leafy greens).

    I interviewed proponents of the Best Bet diet for The MS Show podcast. OMS, WAHLS and BBD each have an episode on the podcast)

    I have ultimately settled on something that works for me and takes my preferred bits of healthy eating regimes.

    I adopt time restricted eating (I fast 16 hours every day) because the process of autophagy scientifically makes sense.

    Sometimes people feel better because they are taking control over an aspect of their life in the unknown world of MS.

    But feeling control is such an important thing that it doesnt matter how you achieve it.

    Find what works for you. OMS has free resources, WAHLS has free resources as does BBD. WAHLS is probably the most costly to implement and there is time involved in preparing bone broth etc.

    I bet you didn’t ask for an essay Greg… I want you to relax and find what is healthy for you.“

  • I am on Mavenclad. Just finished year 2 and last night while brushing my teeth and flossing I found out I had a chipped tooth. I wanted to buy a fluorine toothpaste to help the remineralization process for a limited period. Is it true that fluorine is contraindicated in MS patients?

      • And does Mavenclad can be causing me this problem?
        Since I began on Mavenclad, I start to have hair thinning, fragile nails and teeth sensitivity.
        I never before had these problems. I am wondering if I should consult another doctor for seeing this situation. I have been on vitamin D treatment and I take all my vitamins and have a very good diet.

    • I just finished Mavenclad year 2 in May. Good results about 6 months after year one with improved muscle around knee and an AFO allowing me to walk without tripping after 15 years of foot drop etc. Minimal side effects but much improved sleep and thinking.

  • What I don’t understand is why there is no mention of diet or lifestyle during initial diagnosis? Surely looking at the literature and the research proves beyond any reasonable doubt that a healthy diet can go a long way in improving quality of life, least of all improving debilitating fatigue which affects so many of us? Swank, Wahls, OMS have all shown to improve disability scores in clinical trials. But yet no mention of these diets during consultations. The very mention of diet is met with subtle eye rolling during appointments with my neurologist. This needs to change. People need to be made aware that though diet is by no means a magic bullet it can go a long way in improving your symptoms?

    • Seems to vary quite a bit – every consultation I had touched on the two topics. Much like ProfG, neuros were not keen to give diet recommendations beyond avoiding obviously unhealthy stuff (sugar, processed foods) and increasing veggies and fish.

      Ultimately the evidence just is not there for any protocol, be it OMS, Wahls or keto – note that OMS and keto are almost opposites so go figure… It may well turn out that either can help, depending on your genetics. I suspect that keto would be a rather bad idea for ApoE4 carriers, for one.

  • Yes! And enlightened physiotherapy, ongoing, including NMES, or FES cycling, hydrotherapy, what ever is appropriate- and if this can’t be funded, some advice on where it is available. There are also e stim devices you can purchase for improving muscle function at home. But you need guidance from a physio. And where do you find one? I have been trying to get a response to this question since my diagnosis in 2013!

By Prof G

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