Advertisement

An overview of the current state of evidence for the role of specific diets in multiple sclerosis

Published:September 09, 2019DOI:https://doi.org/10.1016/j.msard.2019.101393

      Highlights

      • Many people are interested in using dietary manipulations to manage their MS.
      • Many diets have been explored in MS and its animal models.
      • Insufficient evidence exists to recommend any specific diet for people with MS.

      Abstract

      Background

      Surveys of people with multiple sclerosis (MS) report that most are interested in using dietary modifications to potentially reduce the severity and symptoms of their disease. This review provides an updated overview of the current state of evidence for the role of specific diets in MS and its animal models, with an emphasis on recent studies including efficacy and safety issues related to dietary manipulations in people with MS.

      Methods

      Studies were identified using a PubMed search for each diet in both MS and experimental autoimmune encephalomyelitis, by review of the reference list of papers identified in the search process, and by searching clinicaltrials.gov for ongoing studies. Each study was evaluated and the data was summarized. Each diet was assigned a level of evidence for its use in MS based on the Quality Rating Scheme for Studies and Other Evidence.

      Results

      Several diets have been explored in people with MS and animal models of MS. Most human trials have been small and non-blinded, limiting their generalizability. Many have also been of short-duration, potentially limiting their ability to find clinically meaningful changes. Presently, insufficient evidence exists to recommend the routine use of any specific diet by people with MS. Clinical trials are ongoing or planned for many diets including the Swank Diet, Wahl's diet, McDougall diet, Mediterranean diet, and intermittent fasting. Results of these studies may help guide clinical recommendations.

      Conclusion

      There is insufficient evidence to recommend the routine use of any specific diet by people with MS. Some diets touted for MS may have potential negative health consequences. It is important that clinicians inquire regarding dietary manipulations, so they can educate patients on any known efficacy data and potential adverse effects of individual diets. Consultation with a registered dietician is recommended for patients undertaking restrictive diets.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Multiple Sclerosis and Related Disorders
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Alter M.
        • Yamoor M.
        • Harshe M.
        Multiple sclerosis and nutrition.
        Arch. Neurol. 1974; https://doi.org/10.1001/archneur.1974.00490400081010
        • Azary S.
        • Schreiner T.
        • Graves J.
        • Waldman A.
        • Belman A.
        • Guttman B.W.
        • Aaen G.
        • Tillema J.M.
        • Mar S.
        • Hart J.
        • Ness J.
        • Harris Y.
        • Krupp L.
        • Gorman M.
        • Benson L.
        • Rodriguez M.
        • Chitnis T.
        • Rose J.
        • Barcellos L.F.
        • Lotze T.
        • Carmichael S.L.
        • Roalstad S.
        • Casper C.T.
        • Waubant E.
        Contribution of dietary intake to relapse rate in early paediatric multiple sclerosis.
        J. Neurol. Neurosurg. Psychiatry. 2018; https://doi.org/10.1136/jnnp-2017-315936
        • Bisht B.
        • Darling W.
        • White E.
        • White K.
        • Shivapour E.T.
        • Zimmerman M.B.
        • Wahls T.
        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; https://doi.org/10.2147/DNND.S128872
        • Bisht B.
        • Darling W.G.
        • Grossmann R.E.
        • Torage Shivapour E.
        • Lutgendorf S.K
        • Snetselaar L.G.
        • Hall M.J.
        • Bridget Zimmerman M.
        • Wahls T.L.
        A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue.
        J. Altern. Complement. Med. 2014; 20: 347-355https://doi.org/10.1089/acm.2013.0188
        • Bisht B.
        • Darling W.G.
        • Shivapour E.T.
        • Lutgendorf S.K.
        • Snetselaar L.G.
        • Chenard C.A.
        • Wahls T.L.
        Multimodal intervention improves fatigue and quality of life in subjects with progressive multiple sclerosis: a pilot study.
        Degener. Neurol. Neuromuscul. Dis. 2015; https://doi.org/10.2147/DNND.S76523
        • Black L.J.
        • Rowley C.
        • Sherriff J.
        • Pereira G.
        • Ponsonby A.-.L.
        • Lucas R.M.
        A healthy dietary pattern associates with a lower risk of a first clinical diagnosis of central nervous system demyelination.
        Mult. Scler. J. 2018; https://doi.org/10.1177/1352458518793524
        • Bock M.
        • Karber M.
        • Kuhn H.
        Ketogenic diets attenuate cyclooxygenase and lipoxygenase gene expression in multiple sclerosis.
        EBioMedicine. 2018; https://doi.org/10.1016/j.ebiom.2018.08.057
        • Brenton J.N.
        • Banwell B.
        • Bergqvist A.G.C.
        • Lehner-Gulotta D.
        • Gampper L.
        • Leytham E.
        • Coleman R.
        • Goldman M.D.
        Pilot study of a ketogenic diet in relapsing-remitting MS.
        Neurol. - Neuroimmunol. Neuroinflammation. 2019; https://doi.org/10.1212/nxi.0000000000000565
        • Brenton J.N.
        • Goldman M.D.
        A study of dietary modi fi cation : perceptions and attitudes of patients with multiple sclerosis.
        Mult. Scler. Relat. Disord. 2016; 8: 54-57https://doi.org/10.1016/j.msard.2016.04.009
        • Choi I.Y.
        • Piccio L.
        • Childress P.
        • Bollman B.
        • Ghosh A.
        • Brandhorst S.
        • Suarez J.
        • Michalsen A.
        • Cross A.H.
        • Morgan T.E.
        • Wei M.
        • Paul F.
        • Bock M.
        • Longo V.D.
        A diet mimicking fasting promotes regeneration and reduces autoimmunity and multiple sclerosis symptoms.
        Cell Rep. 2016; 15: 2136-2146https://doi.org/10.1016/j.celrep.2016.05.009
        • Cignarella F.
        • Cantoni C.
        • Ghezzi L.
        • Salter A.
        • Dorsett Y.
        • Chen L.
        • Phillips D.
        • Weinstock G.M.
        • Fontana L.
        • Cross A.H.
        • Zhou Y.
        • Piccio L.
        Intermittent fasting confers protection in CNS autoimmunity by altering the gut microbiota.
        Cell Metab. 2018; https://doi.org/10.1016/j.cmet.2018.05.006
        • Di Marco R.
        • Mangano K.
        • Quattrocchi C.
        • Amato F.
        • Nicoletti F.
        • Buschard K.
        Exacerbation of protracted-relapsing experimental allergic encephalomyelitis in DA rats by gluten-free diet.
        APMIS. 2004; 112: 651-655https://doi.org/10.1111/j.1600-0463.2004.apm1121003.x
        • Diringer M.
        Neurologic manifestations of major electrolyte abnormalities.
        Handbook of Clinical Neurology. 2017https://doi.org/10.1016/B978-0-444-63599-0.00038-7
        • Éliás S.
        • Schmidt A.
        • Kannan V.
        • Andersson J.
        • Tegnér J.
        TGF-β Affects the differentiation of human GM-CSF+ CD4+ t cells in an Activation- and Sodium-Dependent manner.
        Front. Immunol. 2016; 7: 603https://doi.org/10.3389/fimmu.2016.00603
        • Esquifino A.I.
        • Cano P.
        • Jimenez-Ortega V.
        • Fernández-Mateos M.P.
        • Cardinali D.P.
        Immune response after experimental allergic encephalomyelitis in rats subjected to calorie restriction.
        J. Neuroinflammation. 2007; https://doi.org/10.1186/1742-2094-4-6
        • Esquifino A.I.
        • Cano P.
        • Jiménez V.
        • Cutrera R.A.
        • Cardinali D.P.
        Experimental allergic encephalomyelitis in male Lewis rats subjected to calorie restriction.
        J. Physiol. Biochem. 2004; https://doi.org/10.1007/BF03167069
        • Etemadifar M.
        • Sayahi F.
        • Alroughani R.
        • Toghianifar N.
        • Akbari M.
        • Nasr Z.
        Effects of prolonged fasting on fatigue and quality of life in patients with multiple sclerosis.
        Neurol. Sci. 2016; 37: 929-933https://doi.org/10.1007/s10072-016-2518-9
        • Evans E.
        • Piccio L.
        • Cross A.H.
        Use of vitamins and dietary supplements by patients with multiple sclerosis.
        JAMA Neurol. 2018; https://doi.org/10.1001/jamaneurol.2018.0611
        • Farez M.F.
        • Fiol M.P.
        • Gaitán M.I.
        • Quintana F.J.
        • Correale J.
        Sodium intake is associated with increased disease activity in multiple sclerosis.
        J. Neurol. Neurosurg. Psychiatry. 2015; https://doi.org/10.1136/jnnp-2014-307928
        • Fitzgerald K.C.
        • Munger K.L.
        • Hartung H.P.
        • Freedman M.
        • Montalbán X.
        • Edan G.
        • Wicklein E.M.
        • Radue E.W.
        • Kappos L.
        • Pohl C.
        • Ascherio A.
        • Strasser-Fuchs S.
        • Berger T.
        • Vass K.
        • Sindic C.
        • Dubois B.
        • Dive D.
        • Debruyne J.
        • Metz L.
        • Rice G.
        • Duquette P.
        • Lapierre Y.
        • Traboulsee A.
        • O'Connor P.
        • Štourač P.
        • Talab R.
        • Zapletalova O.
        • Kovařova I.
        • Medova E.
        • Fiedler J.
        • Frederiksen J.
        • Brochet B.
        • Moreau T.
        • Vermersch P.
        • Pelletier J.
        • Clanet M.
        • Clavelou P.
        • Lebrun-Frenay C.
        • Gout O.
        • Kallela M.
        • Pirttila T.
        • Ruutiainen J.
        • Koivisto K.
        • Reunanen M.
        • Elovaara I.
        • Villringer A.
        • Altenkirch H.
        • Wessel K.
        • Steinke W.
        • Kölmel H.
        • Oschmann P.
        • Diem R.
        • Dressel A.
        • Hoffmann F.
        • Baum K.
        • Jung S.
        • Petereit H.
        • Reske D.
        • Sailer M.
        • Kohler J.
        • Sommer N.
        • Hohlfeld R.
        • Henn K.H.
        • Tumani H.
        • Gold R.
        • Rieckmann P.
        • Komoly R.
        • Gacs G.
        • Jakab G.
        • Csiba L.
        • Vecsei L.
        • Miller A.
        • Karussis D.
        • Chapman J.
        • Ghezzi A.
        • Comi G.
        • Gallo P.
        • Cosi V.
        • Durelli L.
        • Anten B.
        • Visser L.
        • Myhr K.M.
        • Szczudlik A.
        • Selmaj K.
        • Stelmasiak Z.
        • Podemski R.
        • Maciejek Z.
        • Cunha L.
        • Sega-Jazbec S.
        • Montalban X.
        • Arbizu T.
        • Saiz A.
        • Barcena J.
        • Arroyo R.
        • Fernandez O.
        • Izquierdo G.
        • Casanova B.
        • Lycke J.
        • Mattle H.
        • Beer K.
        • Coleman R.
        • Chataway J.
        • Riordan J.O.
        • Howell S.
        Sodium intake and multiple sclerosis activity and progression in benefit.
        Ann. Neurol. 2017; https://doi.org/10.1002/ana.24965
        • Fitzgerald K.C.
        • Tyry T.
        • Cofield S.
        • Salter A.
        • Fox R.
        • Cutter G.
        • Marrie R.-.A.
        A survey of current dietary habits within a large population of people with multiple sclerosis.
        Neurology. 2017; 88https://doi.org/10.1016/j.msard.2018.02.019
        • Fitzgerald K.C.
        • Tyry T.
        • Salter A.
        • Cofield S.S.
        • Cutter G.
        • Fox R.
        • Marrie R.A.
        Diet quality is associated with disability and symptom severity in multiple sclerosis.
        Neurology. 2017; https://doi.org/10.1212/WNL.0000000000004768
        • Fitzgerald K.C.
        • Vizthum D.
        • Henry-Barron B.
        • Schweitzer A.
        • Cassard S.D.
        • Kossoff E.
        • Hartman A.L.
        • Kapogiannis D.
        • Sullivan P.
        • Baer D.J.
        • Mattson M.P.
        • Appel L.J.
        • Mowry E.M.
        Effect of intermittent vs. daily calorie restriction on changes in weight and patient-reported outcomes in people with multiple sclerosis.
        Mult. Scler. Relat. Disord. 2018; https://doi.org/10.1016/j.msard.2018.05.002
        • Fontana L.
        Neuroendocrine factors in the regulation of inflammation: excessive adiposity and calorie restriction.
        Exp. Gerontol. 2009; https://doi.org/10.1016/j.exger.2008.04.005
        • Hadgkiss E.J.
        • Jelinek G.A.
        • Weiland T.J.
        • Pereira N.G.
        • Marck C.H.
        • van der Meer D.M.
        The association of diet with quality of life, disability, and relapse rate in an international sample of people with multiple sclerosis.
        Nutr. Neurosci. 2015; 18: 125-136https://doi.org/10.1179/1476830514Y.0000000117
        • Haghikia A.
        • Jörg S.
        • Duscha A.
        • Berg J.
        • Manzel A.
        • Waschbisch A.
        • Hammer A.
        • Lee D.H.
        • May C.
        • Wilck N.
        • Balogh A.
        • Ostermann A.I.
        • Schebb N.H.
        • Akkad D.A.
        • Grohme D.A.
        • Kleinewietfeld M.
        • Kempa S.
        • Thöne J.
        • Demir S.
        • Müller D.N.
        • Gold R.
        • Linker R.A.
        Dietary fatty acids directly impact central nervous system autoimmunity via the small intestine.
        Immunity. 2015; 43: 817-829https://doi.org/10.1016/j.immuni.2015.09.007
        • Hernandez A.L.
        • Kitz A.
        • Wu C.
        • Lowther D.E.
        • Rodriguez D.M.
        • Vudattu N.
        • Deng S.
        • Herold K.C.
        • Kuchroo V.K.
        • Kleinewietfeld M.
        • Hafler D.A.
        Sodium chloride inhibits the suppressive function of FOXP3+ regulatory T cells.
        J. Clin. Invest. 2015; 125: 4212-4222https://doi.org/10.1172/JCI81151
        • Howell O.W.
        • Reeves C.A.
        • Nicholas R.
        • Carassiti D.
        • Radotra B.
        • Gentleman S.M.
        • Serafini B.
        • Aloisi F.
        • Roncaroli F.
        • Magliozzi R.
        • Reynolds R.
        Meningeal inflammation is widespread and linked to cortical pathology in multiple sclerosis.
        Brain. 2011; https://doi.org/10.1093/brain/awr182
        • Hucke S.
        • Eschborn M.
        • Liebmann M.
        • Herold M.
        • Freise N.
        • Engbers A.
        • Ehling P.
        • Meuth S.G.
        • Roth J.
        • Kuhlmann T.
        • Wiendl H.
        • Klotz L.
        Sodium chloride promotes pro-inflammatory macrophage polarization thereby aggravating CNS autoimmunity.
        J. Autoimmun. 2016; 67: 90-101https://doi.org/10.1016/j.jaut.2015.11.001
        • Irish A.
        • Wahls T.
        • Snetselaar L.
        • Erickson C.
        • Darling W.
        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; https://doi.org/10.2147/dnnd.s116949
        • Jahromi S.R.
        • Toghae M.
        • Jahromi M.J.R.
        • Aloosh M.
        Dietary pattern and risk of multiple sclerosis.
        Iran. J. Neurol. 2012;
        • Kafami L.
        • Raza M.
        • Razavi A.
        • Mirshafiey A.
        • Movahedian M.
        • Khorramizadeh M.R.
        Intermittent feeding attenuates clinical course of experimental autoimmune encephalomyelitis in C57BL/6 mice.
        Avicenna J. Med. Biotechnol. 2010;
        • Kim D.Y.
        • Hao J.
        • Liu R.
        • Turner G.
        • Shi F.D.
        • Rho J.M.
        Inflammation-mediated memory dysfunction and effects of a ketogenic diet in a murine model of multiple sclerosis.
        PLoS ONE. 2012; 7https://doi.org/10.1371/journal.pone.0035476
        • Kleinewietfeld M.
        • Manzel A.
        • Titze J.
        • Kvakan H.
        • Yosef N.
        • Linker R.A.
        • Muller D.N.
        • Hafler D.A.
        Sodium chloride drives autoimmune disease by the induction of pathogenic TH17 cells.
        Nature. 2013; 496: 518-522https://doi.org/10.1038/nature11868
        • Lee J.E.
        • Bisht B.
        • Hall M.J.
        • Rubenstein L.M.
        • Louison R.
        • Klein D.T.
        • Wahls T.L.
        A multimodal, nonpharmacologic intervention improves mood and cognitive function in people with multiple sclerosis.
        J. Am. Coll. Nutr. 2017; https://doi.org/10.1080/07315724.2016.1255160
        • Liversedge L.A.
        Treatment and management of multiple sclerosis.
        Br. Med. Bull. 1977; 33: 78-83
        • MacHnik A.
        • Neuhofer W.
        • Jantsch J.
        • Dahlmann A.
        • Tammela T.
        • MacHura K.
        • Park J.K.
        • Beck F.X.
        • Müller D.N.
        • Derer W.
        • Goss J.
        • Ziomber A.
        • Dietsch P.
        • Wagner H.
        • Van Rooijen N.
        • Kurtz A.
        • Hilgers K.F.
        • Alitalo K.
        • Eckardt K.U.
        • Luft F.C.
        • Kerjaschki D.
        • Titze J.
        Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C-dependent buffering mechanism.
        Nat. Med. 2009; https://doi.org/10.1038/nm.1960
        • Marrie R.A.
        Comorbidity in multiple sclerosis: implications for patient care.
        Nat. Rev. Neurol. 2017; https://doi.org/10.1038/nrneurol.2017.33
        • Marrie R.A.
        • Cohen J.
        • Stuve O.
        • Trojano M.
        • Sørensen P.S.
        • Reingold S.
        • Cutter G.
        • Reider N.
        A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview.
        Mult. Scler. J. 2015; https://doi.org/10.1177/1352458514564491
        • Masullo L.
        • Papas M.A.
        • Cotugna N.
        • Baker S.
        • Mahoney L.
        • Trabulsi J.
        Complementary and alternative medicine use and nutrient intake among individuals with multiple sclerosis in the United States.
        J. Community Health. 2014; 40: 153-160https://doi.org/10.1007/s10900-014-9913-z
        • Mattson M.P.
        • Longo V.D.
        • Harvie M.
        Impact of intermittent fasting on health and disease processes.
        Ageing Res. Rev. 2017; https://doi.org/10.1016/j.arr.2016.10.005
        • McDonald J.
        • Graves J.
        • Waldman A.
        • Lotze T.
        • Schreiner T.
        • Belman A.
        • Greenberg B.
        • Weinstock-Guttman B.
        • Aaen G.
        • Tillema J.M.
        • Hart J.
        • Lulu S.
        • Ness J.
        • Harris Y.
        • Rubin J.
        • Candee M.
        • Krupp L.B.
        • Gorman M.
        • Benson L.
        • Rodriguez M.
        • Chitnis T.
        • Mar S.
        • Barcellos L.F.
        • Laraia B.
        • Rose J.
        • Roalstad S.
        • Simmons T.
        • Casper T.C.
        • Waubant E.
        A case-control study of dietary salt intake in pediatric-onset multiple sclerosis.
        Mult. Scler. Relat. Disord. 2016; 6: 87-92https://doi.org/10.1016/j.msard.2016.02.011
        • McDonald T.J.W.
        • Cervenka M.C.
        Ketogenic diets for adult neurological disorders.
        Neurotherapeutics. 2018; https://doi.org/10.1007/s13311-018-0666-8
        • Mente A.
        • De Koning L.
        • Shannon H.S.
        • Anand S.S.
        A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease.
        Arch. Intern. Med. 2009; https://doi.org/10.1001/archinternmed.2009.38
        • Miljković D.
        • Dekanski D.
        • Miljković Ž.
        • Momčilović M.
        • Mostarica-Stojkovic M.
        Dry olive leaf extract ameliorates experimental autoimmune encephalomyelitis.
        Clin. Nutr. 2009; 28: 346-350https://doi.org/10.1016/j.clnu.2009.03.014
        • Most J.
        • Tosti V.
        • Redman L.M.
        • Fontana L.
        Calorie restriction in humans: an update.
        Ageing Res. Rev. 2017; https://doi.org/10.1016/j.arr.2016.08.005
        • Mowry E.M.
        • Azevedo C.J.
        • McCulloch C.E.
        • Okuda D.T.
        • Lincoln R.R.
        • Waubant E.
        • Hauser S.L.
        • Pelletier D.
        Body mass index, but not vitamin d status, is associated with brain volume change in MS.
        Neurology. 2018; https://doi.org/10.1212/WNL.0000000000006644
        • Nourbakhsh B.
        • Graves J.
        • Casper T.C.
        • Lulu S.
        • Waldman A.
        • Belman A.
        • Greenberg B.
        • Weinstock-Guttman B.
        • Aaen G.
        • Tillema J.-.M.
        • Hart J.
        • Ness J.
        • Rubin J.
        • Krupp L.
        • Gorman M.
        • Benson L.
        • Rodriguez M.
        • Chitnis T.
        • Rose J.
        • Barcellos L.
        • Waubant E.
        • Network of Pediatric Multiple Sclerosis Centers
        Dietary salt intake and time to relapse in paediatric multiple sclerosis.
        J. Neurol. Neurosurg. Psychiatry. 2016; 87 (jnnp-2016-313410)https://doi.org/10.1136/jnnp-2016-313410
        • Pani G.
        Neuroprotective effects of dietary restriction: evidence and mechanisms.
        Semin. Cell Dev. Biol. 2015; https://doi.org/10.1016/j.semcdb.2015.03.004
        • Piccio L.
        • Stark J.L.
        • Cross A.H.
        Chronic calorie restriction attenuates experimental autoimmune encephalomyelitis.
        J. Leukoc. Biol. 2008; 84: 940-948https://doi.org/10.1189/jlb.0208133
        • Piccio L.
        • Stark J.L.
        • Cross A.H.
        Chronic calorie restriction attenuates experimental autoimmune encephalomyelitis.
        J. Leukoc. Biol. 2008; https://doi.org/10.1189/jlb.0208133
        • Pinto A.
        • Bonucci A.
        • Maggi E.
        • Corsi M.
        • Businaro R.
        Anti-Oxidant and anti-inflammatory activity of ketogenic diet: new perspectives for neuroprotection in alzheimer's disease.
        Antioxidants. 2018; https://doi.org/10.3390/antiox7050063
        • Raehsler S.L.
        • Choung R.S.
        • Marietta E.V.
        • Murray J.A.
        Accumulation of heavy metals in people on a gluten-free diet.
        Clin. Gastroenterol. Hepatol. 2017; https://doi.org/10.1016/j.cgh.2017.01.034
        • Riccio P.
        • Rossano R.
        • Larocca M.
        • Trotta V.
        • Mennella I.
        • Vitaglione P.
        • Ettorre M.
        • Graverini A.
        • De Santis A.
        • Di Monte E.
        • Coniglio M.G.
        Anti-inflammatory nutritional intervention in patients with relapsing-remitting and primary-progressive multiple sclerosis: a pilot study.
        Exp. Biol. Med. (Maywood). 2016; 241: 620-635https://doi.org/10.1177/1535370215618462
        • Rodrigo L.
        Randomised clinical trial comparing the efficacy of a gluten-free diet versus a regular diet in a series of relapsing-remitting multiple sclerosis patients.
        Int. J. Neurol. Neurother. 2017; 1https://doi.org/10.23937/2378-3001/1/1/1012
        • Rotstein D.L.
        • Cortese M.
        • Fung T.T.
        • Chitnis T.
        • Ascherio A.
        • Munger K.L.
        Diet quality and risk of multiple sclerosis in two cohorts of US women.
        Mult. Scler. J. 2018; https://doi.org/10.1177/1352458518807061
        • Saadatnia M.
        • Etemadifar M.
        • Fatehi F.
        • Ashtari F.
        • Shaygannejad V.
        • Chitsaz A.
        • Maghzi A.H.
        Short-term effects of prolonged fasting on multiple sclerosis.
        Eur. Neurol. 2009; 61: 230-232https://doi.org/10.1159/000197108
        • Schüpbach R.
        • Wegmüller R.
        • Berguerand C.
        • Bui M.
        • Herter-Aeberli I.
        Micronutrient status and intake in omnivores, vegetarians and vegans in Switzerland.
        Eur. J. Nutr. 2017; https://doi.org/10.1007/s00394-015-1079-7
        • Sedaghat F.
        • Jessri M.
        • Behrooz M.
        • Mirghotbi M.
        • Rashidkhani B.
        Mediterranean diet adherence and risk of multiple sclerosis: a case-control study.
        Asia Pac. J. Clin. Nutr. 2016; 25: 377-384https://doi.org/10.6133/apjcn.2016.25.2.12
        • Swank R.L.
        Multiple sclerosis: twenty years on low fat diet.
        Arch. Neurol. 1970; 23: 460https://doi.org/10.1001/archneur.1970.00480290080009
        • Swank R.L.
        • Goodwin J.
        Review of MS patient survival on a Swank low saturated fat diet.
        Nutrition. 2003; 19: 161-162https://doi.org/10.1016/S0899-9007(02)00851-1
        • Swank R.L.
        • Lerstad O.
        • Strøm A.
        • Backer J.
        Multiple sclerosis in rural Norway.
        N. Engl. J. Med. 1952; https://doi.org/10.1056/NEJM195205082461901
        • Swidsinski A.
        • Dörffel Y.
        • Loening-Baucke V.
        • Gille C.
        • Göktas Ö.
        • Reißhauer A.
        • Neuhaus J.
        • Weylandt K.H.
        • Guschin A.
        • Bock M.
        Reduced mass and diversity of the colonic microbiome in patients with multiple sclerosis and their improvement with ketogenic diet.
        Front. Microbiol. 2017; https://doi.org/10.3389/fmicb.2017.01141
        • Thomsen H.L.
        • Jessen E.B.
        • Passali M.
        • Frederiksen J.L.
        The role of gluten in multiple sclerosis: a systematic review.
        Mult. Scler. Relat. Disord. 2019; https://doi.org/10.1016/j.msard.2018.10.019
        • Timmermans S.
        • Bogie J.F.J.
        • Vanmierlo T.
        • Lütjohann D.
        • Stinissen P.
        • Hellings N.
        • Hendriks J.J.a.
        High fat diet exacerbates neuroinflammation in an animal model of multiple sclerosis by activation of the renin angiotensin system.
        J. Neuroimmune Pharmacol. 2013; : 209-217https://doi.org/10.1007/s11481-013-9502-4
        • Wahls T.
        • Scott M.O.
        • Alshare Z.
        • Rubenstein L.
        • Darling W.
        • Carr L.
        • Smith K.
        • Chenard C.A.
        • LaRocca N.
        • Snetselaar L.
        Dietary approaches to treat MS-related fatigue: comparing the modified paleolithic (Wahls elimination) and low saturated fat (Swank) diets on perceived fatigue in persons with relapsing-remitting multiple sclerosis: study protocol for a randomized control.
        Trials. 2018; https://doi.org/10.1186/s13063-018-2680-x
        • Wilck N.
        • Matus M.G.
        • Kearney S.M.
        • Olesen S.W.
        • Forslund K.
        • Bartolomaeus H.
        • Haase S.
        • Mahler A.
        • Balogh A.
        • Marko L.
        • Vvedenskaya O.
        • Kleiner F.H.
        • Tsvetkov D.
        • Klug L.
        • Costea P.I.
        • Sunagawa S.
        • Maier L.
        • Rakova N.
        • Schatz V.
        • Neubert P.
        • Fratzer C.
        • Krannich A.
        • Gollasch M.
        • Grohme D.A.
        • Corte-Real B.F.
        • Gerlach R.G.
        • Basic M.
        • Typas A.
        • Wu C.
        • Titze J.M.
        • Jantsch J.
        • Boschmann M.
        • Dechend R.
        • Kleinewietfeld M.
        • Kempa S.
        • Bork P.
        • Linker R.A.
        • Alm E.J.
        • Muller D.N.
        Salt-responsive gut commensal modulates TH17 axis and disease.
        Nature. 2017; https://doi.org/10.1038/nature24628
        • Wu C.
        • Yosef N.
        • Thalhamer T.
        • Zhu C.
        • Xiao S.
        • Kishi Y.
        • Regev A.
        • Kuchroo V.K.
        Induction of pathogenic TH17 cells by inducible salt-sensing kinase SGK1.
        Nature. 2013; 496: 513-517https://doi.org/10.1038/nature11984
        • Yadav V.
        • Marracci G.
        • Kim E.
        • Spain R.
        • Cameron M.
        • Overs S.
        • Riddehough A.
        • Li D.K.B.
        • McDougall J.
        • Lovera J.
        • Murchison C.
        • Bourdette D.
        Low-fat, plant-based diet in multiple sclerosis: a randomized controlled trial.
        Mult. Scler. Relat. Disord. 2016; 9: 80-90https://doi.org/10.1016/j.msard.2016.07.001
        • Yadav V.
        • Shinto L.
        • Morris C.
        • Senders A.
        • Baldauf-Wagner S.
        • Bourdette D.
        Use and self-reported benefit of complementary and alternative medicine among multiple sclerosis patients.
        Int. J. MS Care. 2006; 8: 5-10https://doi.org/10.7224/1537-2073-8.1.5