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Saxby SM, Ehlinger MA, Brooks L, Titcomb TJ, Ten Eyck P, Rubenstein LM, Bisht B, Shemirani F, Gill C, Kamholtz J, Snetselaar LG, Wahls TL. Feasibility and assessment of self-reported dietary recalls among newly diagnosed multiple sclerosis: a quasi-experimental pilot study. Front Nutr 2024; 11:1369700. [PMID: 39464680 PMCID: PMC11502390 DOI: 10.3389/fnut.2024.1369700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 09/09/2024] [Indexed: 10/29/2024] Open
Abstract
Background Individuals who are newly diagnosed with clinically isolated syndrome (CIS) or relapsing-remitting multiple sclerosis (RRMS) may choose not to undergo disease-modifying therapies (DMTs) due to concerns about expenses or potential adverse effects. Thus, many individuals will opt for alternative therapies, such as dietary modifications. Among these dietary approaches, the modified Paleolithic elimination diet has shown promise for improving MS-related symptoms; however, restriction of certain food groups can lead to inadequate intake of nutrients. Methods Three-day self-reported 24-h dietary recalls using the Automated Self-Administered 24-h (ASA24) Dietary Assessment Tool were assessed during a 12-month quasi-experimental (i.e., non-randomized) trial among individuals who either voluntarily declined DMTs and received health behavior (HB) intervention, (n = 29) or included DMTs and opted for the standard of care (SOC; n = 15). Participants in the HB group received a multimodal intervention that included dietary modifications, a walking program, and breathing exercises. Usual intake of each micronutrient was estimated and then evaluated with the estimated average requirement (EAR)-cut point method. Results At 12 months, >80% of both HB and SOC groups completed 3 days of the self-reported 24-h recalls, indicating the potential feasibility of ASA24. From baseline to 12 months, the HB group had a decreased mean ratio in total grains (0.64; 95% CI 0.43-0.93; p = 0.02) and added sugars (0.52; 95% CI 0.35-0.75; p ≤ 0.001), and an increased mean ratio intake of cured meats (1.74; 95% CI 1.05-2.90; p = 0.04); whereas, the SOC group had a decreased mean ratio intake for beef, veal, pork, lamb, and game meat (0.60; 95% CI 0.40-0.90; p = 0.01). At baseline, both groups had high proportions with inadequate intake of vitamin E and calcium. The SOC group also had a high proportion with inadequate intake of vitamin D. By 12-months, the HB group exhibited severe proportions of nutrient inadequacies (>20% of the group) for vitamin D (43.5%), vitamin E (29.1%), calcium (69.9%), and copper (27.8%). The SOC group, following their own diet, had inadequacies for all the same micronutrients, except for copper, as the HB group. The SOC group also had additional inadequacies: vitamin A (21.3%), thiamin (26.3%), riboflavin (24.2%), folate (24.8%), vitamin B12 (27.8%), and zinc (28.2%). Conclusion Compared to the usual diet, adhering to the modified Paleolithic elimination diet, as a component of a 12-month multimodal intervention, may lead to reduced consumption of specific food groups, such as added sugars, as well as decreased risk of severe proportions of inadequacy for certain nutrients. The utilization of the ASA24 for acquiring dietary recalls from participants with MS may be feasible for future studies. Clinical trial registration clinicaltrials.gov identifier NCT04009005.
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Affiliation(s)
- Solange M. Saxby
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, NH, United States
| | - Mary A. Ehlinger
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Lisa Brooks
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Tyler J. Titcomb
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, United States
| | - Linda M. Rubenstein
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States
| | - Babita Bisht
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Farnoosh Shemirani
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Christine Gill
- Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA, United States
| | - John Kamholtz
- Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA, United States
| | - Linda G. Snetselaar
- Department of Epidemiology, University of Iowa, Iowa City, IA, United States
| | - Terry L. Wahls
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
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Tryfonos C, Chrysafi M, Vadikolias K, Berberoglou L, Vorvolakos T, Dimoliani S, Tsourouflis G, Kontogiorgis C, Antasouras G, Giaginis C. Nutritional interventional studies in patients with multiple sclerosis: a scoping review of the current clinical evidence. J Neurol 2024; 271:1536-1570. [PMID: 38177875 DOI: 10.1007/s00415-023-12140-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/15/2023] [Accepted: 11/25/2023] [Indexed: 01/06/2024]
Abstract
A good nutritional status appears to slow down disease progression and ameliorate symptoms' intensity in patients with multiple sclerosis (MS). Up to date, there are several interventional studies, which have explored the potential beneficial effects of specific dietary patterns as well as specific bioactive nutrients against disease progression and symptomatology of MS patients. This is a thorough, scoping review, which aims to critically summarize and scrutinize the currently available clinical evidence of the potential beneficial effects of nutritional interventional studies against MS progression and symptomatology. This review was conducted to systematically map the research done in this area, as well as to identify gaps in knowledge. For this purpose, we thoroughly explored the most accurate scientific web databases, e.g., PubMed, Scopus, Web of Science, and Google Scholar to achieve the most relevant clinical human studies applying effective and characteristic keywords. There are currently several dietary patterns and specific bioactive nutrients that show promising results by slowing down disease progression and by improving MS symptoms. However, there are also certain conflicting results, while most of the existing studies enrolled a small number of MS patients. Nutritional interventions may exert substantial protective effects against MS progression and symptomatology. However, large, long-term, randomized, double-blind, controlled clinical trials with a prospective design are strongly recommended to delineate whether such nutritional intervention may attenuate disease progression, and improve symptomatology in MS patients.
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Affiliation(s)
- Christina Tryfonos
- Department of Food Science and Nutrition, School of Environment, University of Aegean, 81400, Myrina, Greece
| | - Maria Chrysafi
- Department of Food Science and Nutrition, School of Environment, University of Aegean, 81400, Myrina, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lefteris Berberoglou
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Campus (Dragana) Building 5, 68100, Alexandroupolis, Greece
| | - Theofanis Vorvolakos
- Department of Psychiatry, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Sophia Dimoliani
- Department of Food Science and Nutrition, School of Environment, University of Aegean, 81400, Myrina, Greece
| | - Gerasimos Tsourouflis
- Second Department of Surgery, Propedeutic, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Christos Kontogiorgis
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Campus (Dragana) Building 5, 68100, Alexandroupolis, Greece
| | - Georgios Antasouras
- Department of Food Science and Nutrition, School of Environment, University of Aegean, 81400, Myrina, Greece
| | - Constantinos Giaginis
- Department of Food Science and Nutrition, School of Environment, University of Aegean, 81400, Myrina, Greece.
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Reece JC, Yu M, Bevens W, Simpson-Yap S, Jelinek G, Jelinek P, Davenport R, Nag N, Gray K, Neate S. Study protocol for an online lifestyle modification education course for people living with multiple sclerosis: the multiple sclerosis online course (MSOC). BMC Neurol 2023; 23:249. [PMID: 37386385 DOI: 10.1186/s12883-023-03298-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND People living with multiple sclerosis (plwMS) seek access to information on evidence-based lifestyle-related risk factors associated with multiple sclerosis (MS). As the internet has made delivery of lifestyle information increasingly accessible and cost-effective, we designed the Multiple Sclerosis Online Course (MSOC) to deliver a multimodal lifestyle modification program for plwMS. Two MS online courses were developed: the intervention course based on lifestyle recommendations of the Overcoming Multiple Sclerosis (OMS) program and the standard-care course representing standard lifestyle recommendations from other MS websites. We examined for feasibility in a pilot randomised controlled trial (RCT), where satisfactory completion and accessibility were achieved across both study arms. From this success, a protocol for a larger RCT was developed to examine the effectiveness of MSOC in improving health-related quality of life (HRQoL) and other health outcomes in plwMS. METHODS/DESIGN This single-blinded RCT will recruit n = 1,054 plwMS. Participants in the intervention arm will receive access to a MSOC with seven modules providing evidence-based information on the OMS program. Participants in the control group will receive access to a MSOC of identical format, with seven modules providing general MS-related information and lifestyle recommendations sourced from popular MS websites, e.g. MS societies. Participants will complete questionnaires at baseline and at 6, 12, and 30 months after course completion. The primary endpoint is HRQoL, as measured by MSQOL-54 (both physical and mental health domains) at 12 months following course completion. Secondary outcomes are changes to depression, anxiety, fatigue, disability, and self-efficacy as measured by Hospital Anxiety and Depression Scale, Patient-Determined Disease Steps and University of Washington Self-Efficacy Scale, respectively, assessed at each timepoint. Further assessments will include quantitative post-course evaluation, adoption and maintenance of behaviour change from follow-up survey data, and qualitative analysis of participants' outcomes and reasons for course completion or non-completion. DISCUSSION This RCT aims to determine whether an online intervention course delivering evidence-based lifestyle modification recommendations based on the Overcoming Multiple Sclerosis program to plwMS is more effective at improving HRQoL, and other health outcomes post-intervention, compared with an online standard-care course. TRIAL REGISTRATION This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry, www.anzctr.org.au , identifier ACTRN12621001605886. DATE OF REGISTRATION 25 November 2021.
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Affiliation(s)
- Jeanette C Reece
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
| | - Maggie Yu
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
| | - William Bevens
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
| | - Steve Simpson-Yap
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - George Jelinek
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
| | - Pia Jelinek
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
| | - Rebekah Davenport
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
| | - Nupur Nag
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia
| | - Kathleen Gray
- Centre for Digital Transformation of Health, The University of Melbourne, Melbourne, Australia
| | - Sandra Neate
- Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Level 3, 207 Bouverie St Carlton, Melbourne, VIC, 3053, Australia.
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Zyla-Jackson K, Walton DA, Plafker KS, Kovats S, Georgescu C, Brush RS, Tytanic M, Agbaga MP, Plafker SM. Dietary protection against the visual and motor deficits induced by experimental autoimmune encephalomyelitis. Front Neurol 2023; 14:1113954. [PMID: 36937529 PMCID: PMC10017782 DOI: 10.3389/fneur.2023.1113954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction Five to eight percent of the world population currently suffers from at least one autoimmune disorder. Despite multiple immune modulatory therapies for autoimmune demyelinating diseases of the central nervous system, these treatments can be limiting for subsets of patients due to adverse effects and expense. To circumvent these barriers, we investigated a nutritional intervention in mice undergoing experimental autoimmune encephalomyelitis (EAE), a model of autoimmune-mediated demyelination that induces visual and motor pathologies similar to those experienced by people with multiple sclerosis (MS). Methods EAE was induced in female and male mice and the impact of limiting dietary carbohydrates by feeding a ketogenic diet (KD) enriched in medium chain triglycerides (MCTs), alpha-linolenic acid (an omega-3 fatty acid), and fiber was evaluated in both a preventive regimen (prior to immunization with MOG antigen) and an interventional regimen (following the onset of symptoms). Motor scores were assigned daily and visual acuity was measured using optokinetic tracking. Immunohistochemical analyses of optic nerves were done to assess inflammatory infiltrates and myelination status. Fatty acid and cytokine profiling from blood were performed to evaluate systemic inflammatory status. Results The KD was efficacious when fed as a preventive regimen as well as when initiated as an interventional regimen following symptom onset. The KD minimally impacted body weight during the experimental time course, increased circulating ketones, prevented motor and ocular deficits, preserved myelination of the optic nerve, and reduced infiltration of immune cells to optic nerves. The KD also increased anti-inflammatory-associated omega-3 fatty acids in the plasma and reduced select cytokines in the circulation associated with EAE-mediated pathological inflammation. Discussion In light of ongoing clinical trials using dietary strategies to treat people with MS, these findings support that a KD enriched in MCTs, omega-3 fatty acids, and fiber promotes a systemic anti-inflammatory milieu and ameliorates autoimmune-induced demyelinating visual and motor deficits.
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Affiliation(s)
- Katarzyna Zyla-Jackson
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Dorothy A. Walton
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
| | - Kendra S. Plafker
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
| | - Susan Kovats
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Constantin Georgescu
- Genes and Human Disease Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
| | - Richard S. Brush
- Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Madison Tytanic
- Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Martin-Paul Agbaga
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Scott M. Plafker
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- *Correspondence: Scott M. Plafker
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Elliott-Wherry AN, Lee JE, Pearlman AM, Wahls TL. The Wahls Behavior Change Model for Complex Chronic Diseases: A Clinician's Guide. Degener Neurol Neuromuscul Dis 2022; 12:111-125. [PMID: 36110247 PMCID: PMC9469801 DOI: 10.2147/dnnd.s370173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/19/2022] [Indexed: 12/04/2022] Open
Abstract
Behavior change models are used to understand and intervene on health-related behaviors and outcomes. However, there is a gap in the literature regarding how to create and maintain behavior change in patients with complex chronic diseases such as Multiple Sclerosis (MS). To address this gap, the Wahls Behavior ChangeTM Model (WBCM) (The trademark applies to subsequent mention of the model.) was developed based on existing behavior change theory, empirical evidence, and extensive clinical experience caring for patients with complex chronic diseases. A patient-centered, comprehensive, and multimodal approach, this model provides a framework for understanding and implementing lifestyle behavior change. The overall goals of this paper are to: (1) review existing behavior change theories; (2) introduce the WBCM, including the model's 11 Principles for behavior change in patients with complex chronic diseases; and (3) share how providers can be trained to implement the WBCM. The WBCM can potentially improve short- and longer-term function and quality of life outcomes for people with complex chronic diseases.
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Affiliation(s)
- Alaina N Elliott-Wherry
- Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Jennifer E Lee
- College of Nursing, The University of Iowa, Iowa City, IA, USA
| | - Amy M Pearlman
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Terry L Wahls
- Department of Internal Medicine-General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Titcomb TJ, Brooks L, Smith KL, Ten Eyck P, Rubenstein LM, Wahls TL, Snetselaar LG. Change in Micronutrient Intake among People with Relapsing-Remitting Multiple Sclerosis Adapting the Swank and Wahls Diets: An Analysis of Weighed Food Records. Nutrients 2021; 13:nu13103507. [PMID: 34684508 PMCID: PMC8540533 DOI: 10.3390/nu13103507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/27/2021] [Accepted: 10/01/2021] [Indexed: 12/18/2022] Open
Abstract
The low-saturated fat (Swank) and modified Paleolithic elimination (Wahls) diets have shown promise for MS symptoms; however, due to their restriction of specific foods, inadequate intake of micronutrients is concerning. Therefore, as part of a randomized trial, weighed food records were collected on three consecutive days and were used to evaluate the intake of micronutrients among people with relapsing remitting MS adapting these diets. After randomization to either the Swank or Wahls diets, diet education and support was provided by registered dietitians at baseline and throughout the first 12 weeks of the intervention. Usual intake of each micronutrient was estimated and then evaluated with the EAR-cut point method. At 12 weeks, the Swank group had significant reductions in the proportion with inadequate intake from food for vitamins C, D, and E, while the Wahls group had significant reductions for magnesium and vitamins A, C, D, and E. However, the proportion with inadequate intake significantly increased for calcium, thiamin, and vitamin B12 in the Wahls group and for vitamin A in the Swank group. Inclusion of intake from supplements reduced the proportion with inadequate intake for all micronutrients except calcium among the Wahls group but increased the proportion with excessive intake for vitamin D and niacin among both groups and magnesium among the Swank group. Both diets, especially when including intake from supplements, are associated with reduced inadequate intake compared to the normal diet of people with relapsing remitting MS.
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Affiliation(s)
- Tyler J. Titcomb
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (T.J.T.); (L.B.); (K.L.S.)
- Department of Epidemiology, University of Iowa, Iowa City, IA 52242, USA; (L.M.R.); (L.G.S.)
- Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, IA 52242, USA
| | - Lisa Brooks
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (T.J.T.); (L.B.); (K.L.S.)
| | - Karen L. Smith
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (T.J.T.); (L.B.); (K.L.S.)
- Department of Epidemiology, University of Iowa, Iowa City, IA 52242, USA; (L.M.R.); (L.G.S.)
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA 52242, USA;
| | - Linda M. Rubenstein
- Department of Epidemiology, University of Iowa, Iowa City, IA 52242, USA; (L.M.R.); (L.G.S.)
| | - Terry L. Wahls
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA; (T.J.T.); (L.B.); (K.L.S.)
- Correspondence: ; Tel.: +1-319-384-4421
| | - Linda G. Snetselaar
- Department of Epidemiology, University of Iowa, Iowa City, IA 52242, USA; (L.M.R.); (L.G.S.)
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Wahls TL, Titcomb TJ, Bisht B, Eyck PT, Rubenstein LM, Carr LJ, Darling WG, Hoth KF, Kamholz J, Snetselaar LG. Impact of the Swank and Wahls elimination dietary interventions on fatigue and quality of life in relapsing-remitting multiple sclerosis: The WAVES randomized parallel-arm clinical trial. Mult Scler J Exp Transl Clin 2021; 7:20552173211035399. [PMID: 34377527 PMCID: PMC8326636 DOI: 10.1177/20552173211035399] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the effect of the modified Paleolithic elimination (Wahls) and low-saturated fat (Swank) diets in relapsing-remitting MS (RRMS). Methods Individuals (n = 87) with RRMS were randomized to the Swank or Wahls diets in a parallel group clinical trial consisting of four timepoints: 1) run-in, 2) baseline, 3) 12-weeks, and 4) 24-weeks. Results 77 participants completed 12 weeks and 72 completed 24 weeks. The 12-week change from baseline in fatigue was -0.94 ± 0.18 (FSS) and -9.87 ± 1.93 (MFIS; both p < 0.0001) for Swank, and -0.71 ± 0.24 (FSS; p = 0.004) and -14.41 ± 2.22 (MFIS; p ≤ 0.0001) for Wahls. Physical MSQoL scores improved by 6.04 ± 2.18 (p = 0.006) for Swank and by 14.5 ± 2.63 (p < 0.0001) for Wahls. Mental MSQoL scores improved by 11.3 ± at 2.79 (p < 0.0001) for Wahls while the Swank did not change (3.85 ± 2.63; p = 0.14). Neither group showed significant changes in 6-minute walking distance at 12 weeks. All outcomes were maintained or further improved at 24 weeks. Conclusions Both diets were associated with clinically meaningful within-group reductions in fatigue and improvements in QoL.Trial Registration: Clinicaltrials.gov Identifier: NCT02914964.
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Affiliation(s)
- Terry L Wahls
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Tyler J Titcomb
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Babita Bisht
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | | | - Lucas J Carr
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Warren G Darling
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA, USA
| | - Karin F Hoth
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - John Kamholz
- Department of Neurology, University of Iowa, Iowa City, IA, USA
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Wahls T, Titcomb T, Bisht B, Ramanathan M. Patient Empowerment and the Exclusion of Dietary Intervention Studies. Comment on "Diet and Multiple Sclerosis: Scoping Review of Web-Based Recommendations". Interact J Med Res 2021; 10:e17063. [PMID: 33595444 PMCID: PMC7929754 DOI: 10.2196/17063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/27/2021] [Indexed: 01/30/2023] Open
Affiliation(s)
- Terry Wahls
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Tyler Titcomb
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States.,Department of Epidemiology, University of Iowa, Iowa City, IA, United States
| | - Babita Bisht
- Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Murali Ramanathan
- Department of Pharmaceutical Sciences, State University of New York, Buffalo, NY, United States.,Department of Neurology, State University of New York, Buffalo, NY, United States
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Current Evidence on the Efficacy of Gluten-Free Diets in Multiple Sclerosis, Psoriasis, Type 1 Diabetes and Autoimmune Thyroid Diseases. Nutrients 2020; 12:nu12082316. [PMID: 32752175 PMCID: PMC7468712 DOI: 10.3390/nu12082316] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/13/2022] Open
Abstract
In this review, we summarize the clinical data addressing a potential role for gluten in multiple sclerosis (MS), psoriasis, type 1 diabetes (T1D) and autoimmune thyroid diseases (ATDs). Furthermore, data on the prevalence of celiac disease (CD) and gluten-related antibodies in the above patient groups are presented. Adequately powered and properly controlled intervention trials investigating the effects of a gluten-free diet (GFD) in non-celiac patients with MS, psoriasis, T1D or ATDs are lacking. Only one clinical trial has studied the effects of a GFD among patients with MS. The trial found significant results, but it is subject to major methodological limitations. A few publications have found beneficial effects of a GFD in a subgroup of patients with psoriasis that were seropositive for anti-gliadin or deamidated gliadin antibodies, but no effects were seen among seronegative patients. Studies on the role of gluten in T1D are contradictive, however, it seems likely that a GFD may contribute to normalizing metabolic control without affecting levels of islet autoantibodies. Lastly, the effects of a GFD in non-celiac patients with ATDs have not been studied yet, but some publications report that thyroid-related antibodies respond to a GFD in patients with concomitant CD and ATDs. Overall, there is currently not enough evidence to recommend a GFD to non-celiac patients with MS, psoriasis, ATDs or T1D.
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Eating Pattern and Nutritional Risks among People with Multiple Sclerosis Following a Modified Paleolithic Diet. Nutrients 2020; 12:nu12061844. [PMID: 32575774 PMCID: PMC7353368 DOI: 10.3390/nu12061844] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Preliminary studies suggest that a modified Paleolithic diet may benefit symptoms of fatigue in progressive multiple sclerosis (MS). However, this diet restricts the consumption of eggs, dairy, and gluten-containing grains, which may increase the risk of micronutrient deficiencies. Therefore, we evaluated the nutritional safety of this diet among people with progressive MS. Three nonconsecutive 24-h dietary recalls were collected from (n = 19) progressive MS participants in the final months of a diet intervention study and analyzed using Nutrition Data System for Research (NDSR) software. Food group intake was calculated, and intake of micronutrients was evaluated and compared to individual recommendations using Nutrient Adequacy Ratios (NARs). Blood was drawn at baseline and the end of the study to evaluate biomarker changes. Mean intake of fruits and vegetables exceeded nine servings/day and most participants excluded food groups. The intake of all micronutrients from food were above 100% NAR except for vitamin D (29.6 ± 34.6%), choline (73.2 ± 27.2%), and calcium (60.3 ± 22.8%), and one participant (1/19) exceeded the Tolerable Upper Limit (UL) for zinc, one (1/19) for vitamin A, and 37% (7/19) exceeded the chronic disease risk reduction (CDRR) for sodium. When intake from supplements was included in the analysis, several individuals exceeded ULs for magnesium (5/19), zinc (2/19), sodium (7/19), and vitamins A (2/19), D (9/19), C (1/19), B6 (3/19), and niacin (10/19). Serum values of vitamins D, B12, K1, K2, and folate significantly increased compared to respective baseline values, while homocysteine and magnesium values were significantly lower at 12 months. Calcium and vitamin A serum levels did not change. This modified Paleolithic diet is associated with minimal nutritional risks. However, excessive intake from supplements may be of concern.
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Miller ED, Dziedzic A, Saluk-Bijak J, Bijak M. A Review of Various Antioxidant Compounds and their Potential Utility as Complementary Therapy in Multiple Sclerosis. Nutrients 2019; 11:nu11071528. [PMID: 31284389 PMCID: PMC6682972 DOI: 10.3390/nu11071528] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is a complex disease of the central nervous system (CNS). The etiology of this multifactorial disease has not been clearly defined. Conventional medical treatment of MS has progressed, but is still based on symptomatic treatment. One of the key factors in the pathogenesis of MS is oxidative stress, enhancing inflammation and neurodegeneration. In MS, both reactive oxygen and nitrogen species are formed in the CNS mainly by activated macrophages and microglia structures, which can lead to demyelination and axon disruption. The course of MS is associated with the secretion of many inflammatory and oxidative stress mediators, including cytokines (IL-1b, IL-6, IL-17, TNF-α, INF-γ) and chemokines (MIP-1a, MCP-1, IP10). The early stage of MS (RRMS) lasts about 10 years, and is dominated by inflammatory processes, whereas the chronic stage is associated with neurodegenerative axon and neuron loss. Since oxidative damage has been known to be involved in inflammatory and autoimmune-mediated processes, antioxidant therapy could contribute to the reduction or even prevention of the progression of MS. Further research is needed in order to establish new aims for novel treatment and provide possible benefits to MS patients. The present review examines the roles of oxidative stress and non-pharmacological anti-oxidative therapies in MS.
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Affiliation(s)
- Elzbieta Dorota Miller
- Department of Physical Medicine, Medical University of Lodz, Pl. Hallera 1, 90-647 Lodz, Poland
- Neurorehabilitation Ward, General Hospital no III, Milionowa 14, 90-001 Lodz, Poland
| | - Angela Dziedzic
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska 141/143, 90-236 Lodz, Poland
| | - Joanna Saluk-Bijak
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska 141/143, 90-236 Lodz, Poland
| | - Michal Bijak
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska 141/143, 90-236 Lodz, Poland.
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Fellows Maxwell K, Wahls T, Browne RW, Rubenstein L, Bisht B, Chenard CA, Snetselaar L, Weinstock-Guttman B, Ramanathan M. Lipid profile is associated with decreased fatigue in individuals with progressive multiple sclerosis following a diet-based intervention: Results from a pilot study. PLoS One 2019; 14:e0218075. [PMID: 31211794 PMCID: PMC6581256 DOI: 10.1371/journal.pone.0218075] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 05/14/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose To investigate associations between lipid profiles and fatigue in a cohort of progressive multiple sclerosis (MS) patients on a diet-based multimodal intervention. Methods This pilot study included 18 progressive MS patients who participated in a prospective longitudinal study of fatigue following a diet-based multimodal intervention that included exercise, neuromuscular electrical stimulation and stress reduction. The diet recommended high intake of vegetables and fruits, encouraged consumption of animal and plant protein and excluded foods with gluten-containing grains, dairy and eggs. Fatigue was measured on the Fatigue Severity Scale (FSS) at baseline and every 3 months for 12 months. A lipid profile consisting of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and triglycerides (TG) was obtained on fasting blood samples at baseline and 12 months. Results FSS scores decreased from a baseline of 5.51 (95% CI: 4.86, 6.16) to a mean of 3.03 (95% CI: 2.23, 3.82) at 12 months (p < 0.001). At 12 months, increases in HDL-C (mean change: +6.0 mg/dl; 95% CI: 0.3, 12.0; p = 0.049) and decreases in BMI (mean change: -2.6 kg/m2; 95% CI: -3.6, -2.5; p < 0.001), LDL-C (mean change: -10.4 mg/dl; 95% CI:-19.7, -1.2; p = 0.029), TG (mean change: -29.2 mg/dl; 95% CI: -44.3, -14.2; p = 0.001), TG to HDL-C ratio (mean change: -0.6; 95% CI: -1.0, -0.3; p = 0.002) and TC to HDL-C ratio (mean change:-0.6; 95% CI: -1.0, -0.3; p = 0.003) were observed compared to baseline. Improvements in FSS were associated with increases in HDL-C (β = -0.05; 95% CI: -0.1, -0.0004; p = 0.048) and changes in TC (p = 0.005) from baseline to 12 months. Conclusions Lipid profile variables are associated with improvements in fatigue in progressive MS patients on a diet-based multimodal intervention.
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Affiliation(s)
- Kelly Fellows Maxwell
- Department of Pharmaceutical Sciences, State University of New York, Buffalo, New York, United States of America
| | - Terry Wahls
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
- Department of Neurology, University of Iowa, Iowa City, Iowa, United States of America
| | - Richard W. Browne
- Department of Biotechnical and Clinical Laboratory Sciences, State University of New York, Buffalo, New York, United States of America
| | - Linda Rubenstein
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
| | - Babita Bisht
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Catherine A. Chenard
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Linda Snetselaar
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
| | - Bianca Weinstock-Guttman
- Department of Neurology, State University of New York, Buffalo, New York, United States of America
| | - Murali Ramanathan
- Department of Pharmaceutical Sciences, State University of New York, Buffalo, New York, United States of America
- Department of Neurology, State University of New York, Buffalo, New York, United States of America
- * E-mail:
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Nutrient Composition Comparison between the Low Saturated Fat Swank Diet for Multiple Sclerosis and Healthy U.S.-Style Eating Pattern. Nutrients 2019; 11:nu11030616. [PMID: 30871265 PMCID: PMC6470969 DOI: 10.3390/nu11030616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS) is an incurable degenerative disease that attacks the central nervous system. Roy Swank proposed a low saturated fat diet to treat MS around 1950 and showed delayed disease progression in his patients. However, there is insufficient evidence to recommend this diet for MS and default dietary recommendations are the Dietary Guidelines for Americans (DGA). This study assessed the nutritional adequacy of seven-day menus developed by Swank and their compliance with the DGA; menus were modeled for comparison with the DGA Healthy US-Style Eating Pattern (HEP) for males and females 31⁻50 years. Swank recommended dietary supplements corrected menu shortfalls in vitamins D, E, calcium, folate and iron but not dietary fiber, potassium and choline. Healthy Eating Index-2015 score for Swank menus (93.2/100) indicated good compliance with the DGA. Nutritional adequacy of the Swank modeled diet was similar to HEP for 17 vitamins and minerals (Mean Adequacy Ratios ≥94%) with similar shortfall nutrients except magnesium (HEP males) and dietary fiber (Swank males). Alternate Healthy Eating Index-2010 scores for Swank male (90/110) and female (88/110) model diets were similar to HEP. Swank menus have similar nutritional adequacy as HEP. Inclusion of foods high in dietary fiber, potassium and choline may be advised as well as selection of foods to reduce sodium below the Tolerable Upper Intake Level.
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Chenard CA, Rubenstein LM, Snetselaar LG, Wahls TL. Nutrient Composition Comparison between a Modified Paleolithic Diet for Multiple Sclerosis and the Recommended Healthy U.S.-Style Eating Pattern. Nutrients 2019; 11:E537. [PMID: 30832289 PMCID: PMC6470485 DOI: 10.3390/nu11030537] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 01/04/2023] Open
Abstract
Multiple sclerosis (MS) is a demyelinating disease that attacks the central nervous system. Evidence-based dietary guidelines do not exist for MS; the default advice is to follow the Dietary Guidelines for Americans (DGA). A modified Paleolithic Wahls Elimination (WahlsElim) diet promoted for MS excludes grains and dairy and encourages 9+ cups fruits and vegetables (F/V) and saturated fat for cooking. This study evaluated the nutritional adequacy of seven-day menus and modeled them with varying amounts of F/V for comparison with the DGA Healthy US-Style Eating Pattern (HEP) for ages 31⁻50 years. WahlsElim menus had low added sugar and glycemic index. Nutritional adequacy of the menus and modeled versions were similar to HEP for 17 vitamins and minerals (mean adequacy ratio ≥92%). Nutrient shortfalls for the modeled diet with 60% F/V were identical to HEP for vitamin D, iron (females), magnesium (marginally males), choline and potassium; this modeled diet was also low in dietary fiber and calcium but met vitamin E requirements while HEP did not. WahlsElim-prescribed supplements corrected vitamin D and magnesium shortfalls; careful selection of foods are needed to meet requirements of other shortfall nutrients and reduce saturated fat and sodium. Doctors should monitor nutritional status, supplement doses, and possible contraindications to high vitamin K intake in individuals following the WahlsElim diet.
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Affiliation(s)
- Catherine A Chenard
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA.
| | - Linda M Rubenstein
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA.
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA.
| | - Terry L Wahls
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA.
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Wahls TL, Chenard CA, Snetselaar LG. Review of Two Popular Eating Plans within the Multiple Sclerosis Community: Low Saturated Fat and Modified Paleolithic. Nutrients 2019; 11:E352. [PMID: 30736445 PMCID: PMC6412750 DOI: 10.3390/nu11020352] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/23/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023] Open
Abstract
The precise etiology of multiple sclerosis (MS) is unknown but epidemiologic evidence suggests this immune-mediated, neurodegenerative condition is the result of a complex interaction between genes and lifetime environmental exposures. Diet choices are modifiable environmental factors that may influence MS disease activity. Two diets promoted for MS, low saturated fat Swank and modified Paleolithic Wahls Elimination (WahlsElim), are currently being investigated for their effect on MS-related fatigue and quality of life (NCT02914964). Dr. Swank theorized restriction of saturated fat would reduce vascular dysfunction in the central nervous system (CNS). Dr. Wahls initially theorized that detailed guidance to increase intake of specific foodstuffs would facilitate increased intake of nutrients key to neuronal health (Wahls™ diet). Dr. Wahls further theorized restriction of lectins would reduce intestinal permeability and CNS inflammation (WahlsElim version). The purpose of this paper is to review the published research of the low saturated fat (Swank) and the modified Paleolithic (Wahls™) diets and the rationale for the structure of the Swank diet and low lectin version of the Wahls™ diet (WahlsElim) being investigated in the clinical trial.
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Affiliation(s)
- Terry L Wahls
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
| | - Catherine A Chenard
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA.
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Wahls T, Scott MO, Alshare Z, Rubenstein L, Darling W, Carr L, Smith K, Chenard CA, 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 controlled trial. Trials 2018; 19:309. [PMID: 29866196 PMCID: PMC5987638 DOI: 10.1186/s13063-018-2680-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/08/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Fatigue is one of the most disabling symptoms of multiple sclerosis (MS) and contributes to diminishing quality of life. Although currently available interventions have had limited success in relieving MS-related fatigue, clinically significant reductions in perceived fatigue severity have been reported in a multimodal intervention pilot study that included a Paleolithic diet in addition to stress reduction, exercise, and electrical muscle stimulation. An optimal dietary approach to reducing MS-related fatigue has not been identified. To establish the specific effects of diet on MS symptoms, this study focuses on diet only instead of the previously tested multimodal intervention by comparing the effectiveness of two dietary patterns for the treatment of MS-related fatigue. The purpose of this study is to determine the impact of a modified Paleolithic and low saturated fat diet on perceived fatigue (primary outcome), cognitive and motor symptoms, and quality of life in persons with relapsing-remitting multiple sclerosis (RRMS). METHODS/DESIGN This 36-week randomized clinical trial consists of three 12-week periods during which assessments of perceived fatigue, quality of life, motor and cognitive function, physical activity and sleep, diet quality, and social support for eating will be collected. The three 12-week periods will consist of the following: 1. OBSERVATION Participants continue eating their usual diet. 2. INTERVENTION Participants will be randomized to a modified Paleolithic or low saturated fat diet for the intervention period. Participants will receive support from a registered dietitian (RD) through in-person coaching, telephone calls, and emails. 3. FOLLOW-UP Participants will continue the study diet for an additional 12 weeks with minimal RD support to assess the ability of the participants to sustain the study diet on their own. DISCUSSION Because fatigue is one of the most common and disabling symptoms of MS, effective management and reduction of MS-related fatigue has the potential to increase quality of life in this population. The results of this study will add to the evidence base for providing dietary recommendations to treat MS-related fatigue and other symptoms associated with this disease. TRIAL REGISTRATION ClinicalTrials.gov, NCT02914964 . Registered on 24 August 2016.
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Affiliation(s)
| | | | | | | | | | - Lucas Carr
- University of Iowa, Iowa City, Iowa, USA
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