Two major research reviews just answered a question I get asked constantly: What is the best diet for people with MS?
Diet and nutrition can have a huge impact on symptom worsening, disability progression, and overall quality of life. And we now have solid evidence showing which dietary approaches work best.
In this blog, I’ll walk you through two important meta-analyses on diet and multiple sclerosis. The first one examined how adding a Mediterranean diet to a common MS medication affects relapse rates and disability. The second compared eight different diets head-to-head to see which ones actually reduced fatigue and improved quality of life.
Before we dive into the findings, let me explain what makes these studies so powerful.
A meta-analysis is a research technique that pools results from multiple studies to get a clearer picture of whether an intervention actually works. Instead of relying on just one small study, researchers use a systematic strategy to find all the studies that meet their pre-defined criteria. Then, two independent researchers review each study to confirm the results and check for bias. They use statistics to analyze the combined data and create what’s called a 95% confidence interval.
If the 95% confidence interval falls entirely on the side favoring the intervention, you can confidently say that the intervention in question is genuinely helpful for that specific outcome.
Now let’s look at what two recent meta-analyses revealed about diet and MS.
This meta-analysis looked specifically at randomized controlled studies that combined a Mediterranean diet with one particular disease-modifying treatment (DMT) — dimethyl fumarate, also known by the brand name Tecfidera.
Because different MS medications can affect relapse rates and new brain lesions in different ways, having everyone in these studies on the same medication reduces a major source of variation. It makes it much easier to see what the diet itself is contributing.
The researchers included seven randomized controlled studies with a total of 1,118 participants with relapsing-remitting MS. Most of the studies were conducted in Iran (five studies), with one in Sweden and one in Turkey. They looked at three specific outcomes: annual relapse rate, disability progression (measured by something called the Expanded Disability Status Scale, or EDSS), and quality of life scores.
Relapse Rate
Three studies involving 468 people examined relapse rates. The results showed that people who adopted a Mediterranean diet while taking dimethyl fumarate had a 31% lower risk of relapse compared to those on the medication alone. The statistical analysis was extremely strong — you can confidently say that combining the Mediterranean diet with this medication further reduces relapse risk beyond what the medication does on its own.
Disability Progression
Four studies with 650 participants measured disability using the EDSS scale. Those who followed a Mediterranean diet showed significantly less disability progression compared to the control group. Again, the confidence interval clearly favored the diet intervention.
Quality of Life
This is where things get interesting. Three studies involving 503 people measured quality of life using a standard MS assessment tool that looks at both physical health and mental health. The Mediterranean diet did not show statistically significant improvements in either physical or mental quality of life scores.
So the Mediterranean diet helped with relapse rates and disability progression, but not with how people actually felt day-to-day. Keep that finding in mind as we look at the next study.
This earlier meta-analysis used a different approach called a network meta-analysis, which allows researchers to compare three or more interventions simultaneously. This is powerful because you can not only see which diets work, but also rank them against each other to see which ones work best.
Dr. Snetselaar and her team found 12 randomized diet studies involving 608 participants. They compared eight different dietary approaches: Paleolithic, Low-fat, Mediterranean, Fasting, Calorie Restriction, Ketogenic, Anti-inflammatory, and a Control diet. The outcomes they measured were fatigue and quality of life (both physical and mental).
Because the 12 studies used different assessment tools to measure fatigue and quality of life, the researchers had to standardize the results using something called a standardized mean difference (SMD) with a 95% confidence interval. The key thing to look for: if the confidence interval falls entirely on the side of the diet intervention, that diet likely helps with the outcome being measured.
Fatigue Results
Three diets showed clear benefits for reducing fatigue compared to control:
Paleolithic diet reduced fatigue the most (SMD -1.27)Low-fat diet reduced fatigue (SMD -0.90)Mediterranean diet reduced fatigue (SMD -0.89)
The Ketogenic diet also reduced fatigue, but the confidence interval wasn’t strong enough to draw solid conclusions. Fasting and Anti-inflammatory diets had minimal impact on fatigue.
Here’s an important finding: The Calorie Restriction diet actually made fatigue significantly worse.
Quality of Life Results
For improving physical quality of life, two diets stood out:
Paleolithic diet (SMD 1.01)
Mediterranean diet (SMD 0.47)
Paleolithic diet (SMD 0.81)
Mediterranean diet (SMD 0.36)
The Ketogenic and Low-fat diets showed some improvements in both physical and mental quality of life, but the confidence intervals weren’t strong enough to draw firm conclusions. Calorie Restriction, Fasting, and Anti-inflammatory diets didn’t improve quality of life.
My Takeaway: What This Research Means for You
I’m excited to see more dietary intervention studies being conducted in MS research. Our own study at the University of Iowa, “Efficacy of Diet on Quality of Life,” will complete its last study visit in July 2026, and we’ll likely be presenting findings at MS conferences in 2027.
But here’s what we can learn from these two meta-analyses right now:
The Mediterranean Diet + Medication Connection
The first study showed that adding a Mediterranean diet to dimethyl fumarate (Tecfidera) further reduced relapse risk and disability progression beyond what the medication achieved alone. That’s significant.
Let me explain how this medication works, because it connects to how diet helps. Dimethyl fumarate activates something called the nuclear factor erythroid 2 related factor (Nrf2) pathway, which then inhibits another pathway called nuclear factor kappa B (NF-kappa B).(3) This blocks inflammation-producing molecules like TNF-alpha, IL-1, and IL-6, which calms excessive inflammation and reduces the risk of relapses and new brain lesions.
Dimethyl fumarate is as potent as many of the infusion medications. But here’s the exciting part: adding better nutrition amplified its benefits even more.
The Diet Rankings Tell an Important Story
The second study — the network meta-analysis — revealed something crucial: not all diets are equally effective for MS symptoms.
The Paleolithic and Mediterranean diets came out on top for reducing fatigue and improving quality of life. The Paleolithic diet was roughly 30% more effective than Mediterranean for reducing fatigue, and about twice as effective for improving both physical and mental quality of life.
This helps explain the puzzle from the first study. The Mediterranean diet reduced relapses and disability progression but didn’t significantly improve quality of life scores. The network meta-analysis suggests that while Mediterranean helps, Paleolithic may be more effective for how you actually feel day-to-day.
How Diet Works at the Cellular Level
You can stimulate that same Nrf2 pathway that dimethyl fumarate activates by eating significantly more non-starchy vegetables and berries. This is exactly what both Mediterranean and Paleolithic diets emphasize — lots of colorful plant foods.
I believe part of the mechanism behind why these diets work is through activating the Nrf2 pathway naturally through food. When you eat foods rich in certain plant compounds, you’re essentially getting some of the same anti-inflammatory benefits as the medication, but from your plate.
Practical Steps You Can Take
Have a family meeting and discuss how you could add more green leafy vegetables and berries to your weekly meals. This is important enough to make it a household priority, not just something you tackle alone.
If you’re working with a healthcare provider who prescribes dimethyl fumarate, consider adopting a Mediterranean or Paleolithic diet alongside it. The evidence suggests this combination can be particularly powerful.
Beyond Food: Supplements That Support the Nrf2 Pathway
You don’t have to rely solely on prescription medications to boost the Nrf2 pathway. Several natural compounds can stimulate Nrf2 and inhibit NF-kappa B, including pterostilbene, curcumin, glucoraphanin (from broccoli sprouts), and epigallocatechin-3-gallate (from green tea).(4-6) These compounds are included in Cytokine Modulator.
I also encourage people with MS to ensure their vitamin D levels are in the top half of the reference range. Get outside. Get some sun exposure without getting sunburned. And take both vitamin D3 and vitamin K2 together. Vitamin K2 is important because it helps facilitate myelin repair and supports getting calcium into your teeth and bones where it belongs.
There’s a lot you can do to support your healing journey, and this research confirms that dietary choices can make a meaningful difference in both disease progression and how you feel.
Citations1. Kong J, Kong J, Wen S, Yang K, Tang J. Efficacy of the Mediterranean diet in the treatment of multiple sclerosis (RRMS): A systematic review and meta-analysis. Mult Scler Relat Disord. 2025;104:106739.Snetselaar LG, Cheek JJ, Fox SS, Healy HS, Schweizer ML, Bao W, et al. Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systematic Review and Network Meta-analysis of Randomized Trials. Neurology. 2023;100(4):e357-e66.Yadav SK, Soin D, Ito K, Dhib-Jalbut S. Insight into the mechanism of action of dimethyl fumarate in multiple sclerosis. J Mol Med (Berl). 2019;97(4):463-72.Sonzogni E, Martinelli G, Fumagalli M, Maranta N, Pozzoli C, Bani C, et al. In Vitro Insights into the Dietary Role of Glucoraphanin and Its Metabolite Sulforaphane in Celiac Disease. Nutrients. 2024;16(16).Ashrafizadeh M, Ahmadi Z, Mohammadinejad R, Farkhondeh T, Samarghandian S. Curcumin Activates the Nrf2 Pathway and Induces Cellular Protection Against Oxidative Injury. Curr Mol Med. 2020;20(2):116-33.Scapagnini G, Vasto S, Abraham NG, Caruso C, Zella D, Fabio G. Modulation of Nrf2/ARE pathway by food polyphenols: a nutritional neuroprotective strategy for cognitive and neurodegenerative disorders. Mol Neurobiol. 2011;44(2):192-201.
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