Multiple Sclerosis and the Effects of Ketogenic Diet Therapy

The Effects of Ketogenic Diet Therapy Versus the Mediterranean Diet on Quality of Life in a Group of Patients With Multiple Sclerosis - the KETOMED-MS Study

Multiple sclerosis (MS) is an inflammatory and immune-mediated neurological disease with multifactorial etiology. The specific etiopathogenetic mechanisms of MS are still unknown but it is clear that it results from a combination of genetic and environmental factors. Several studies have reported the possible role of diet as a risk factor for MS and its progression. To date, many dietary patterns and their association with MS have been studied, but data is still limited and inconclusive. Mediterranean Diet (MedDiet) has been associated with a lower risk of developing MS, compared to a Western-style diet. In one of investigators' studies, higher MedDiet adherence was associated with a 6-fold greater likelihood of having lower disease severity than those with low adherence. A significant restriction of carbohydrates (up to ketogenesis) can have beneficial effects on various parameters (inflammatory markers, oxidative stress, altered glucose metabolism) which are altered in subjects with MS. Ketogenic diet therapies (KDTs) have been recommended mainly for children with drug-resistant epilepsy, but in recent years they have been applied to Multiple Sclerosis. Preclinical studies in animal models evaluating the efficacy of KDTs in experimental autoimmune encephalomyelitis (EAE) found a beneficial effect of diet in slowing of disease progression, improvement of motor disability, reduction of inflammatory cytokines and reactive oxygen species. In a randomized study, improvements in health-related quality of life (HRQL) scores and a slight decrease in EDSS scores were found. An open-label, single-arm study of 20 patients with RRMS also reported that, after 6 months of MAD, no subjects had new or enlarging FLAIR/T2 lesions, with a significant improvement in the EDSS score, the Modified Fatigue Impact Scale subscales and arm. A 3-arm parallel-arm randomized controlled pilot study was planned to determine the effectiveness of a modified Atkins diet (MAD) compared to a Mediterranean diet (MedDiet) on quality of life in a population with MS.

Study Overview

• Status: Recruiting
• Conditions: Multiple Sclerosis, Relapsing-Remitting
• Intervention / Treatment: Dietary supplement: Mediterranean Diet; Dietary supplement: Ketogenic Diet; Dietary supplement: Control group

Detailed Description

Multiple sclerosis (MS) is an inflammatory and immune-mediated neurological disease with multifactorial etiology. MS is one of the most important causes of disability in young adults and affects more women than men (with a male-female incidence ratio between 1.5:1 and 2.5:1). The specific etiopathogenetic mechanisms of MS are still unknown but it is clear that it derives from a combination of genetic and environmental factors. Several studies have reported the possible role of diet as a risk factor for MS and its progression. The possible role of dietary components on neuroinflammation, one of the main pathogenetic mechanisms of MS, has attracted a lot of interest. Diet and dietary components can be beneficial not only on MS symptoms but also on disease progression and disability status. To date, many dietary patterns and their association with MS have been studied, but the data is still limited and inconclusive. Notably, previous observational studies have found that MS patients tend to have a less healthy or more pro-inflammatory diet, compared to controls. Recently, Alfredsson and colleagues evaluated the risk of MS based on adherence to different dietary patterns (Western, Mediterranean and vegan/vegetarian diets). The authors reported that the Mediterranean Diet (MedDiet) was associated with a lower risk of developing MS, compared to a Western-style diet, while no significant associations were described between the vegetarian/vegan diet and the risk of MS. The positive association between MedDiet adherence and improved MS severity was recently confirmed by our study, in which high MedDiet adherence was associated with a 6-fold greater likelihood of having a lower severity of disease compared to those with low adherence to the MedDiet. Over the years, researchers have studied not only the neurological aspects of the disease but also the metabolic characteristics of MS patients. Insulin resistance, inflammatory markers, oxidative stress have been and are currently the main topics of interest. Studies have highlighted that MS is associated with altered glucose and insulin metabolism, which can negatively influence cognitive decline and dysfunction. All of these mechanisms can be modified through significant carbohydrate restriction that decreases glycemia and insulin levels and leads to ketogenesis. Dietary interventions aimed at inducing therapeutic ketosis are called ketogenic diet therapies (KDTs) and include different dietary regimes: the classic ketogenic diet (cKD), the medium chain triglyceride (MCT) diet, the modified Atkins diet (MAD). These protocols have been recommended mainly for children with drug-resistant epilepsy, but in recent years they have been applied to several other neurological pathologies such as Alzheimer's, Parkinson's and, recently, Multiple Sclerosis. Preclinical studies in animal models evaluating the efficacy of KDTs in experimental autoimmune encephalomyelitis (EAE) found a beneficial effect of diet. In particular, KDT slowed disease progression, improved motor disability, reduced inflammatory cytokines and reactive oxygen species. Choi et al. (2016) enrolled 60 patients with relapsing-remitting MS (RRMS) in a randomized, parallel 3-arm study to evaluate the safety and feasibility of a 6-month KDT or fasting-mimicking diets (FMD) on patients' quality of life. The study reported improvements in health-related quality of life (HRQL) scores of both the KDT group and the FMD group, at 3 and 6 months. Furthermore, a slight decrease in EDSS scores was reported in the FMD and KDT groups. An open-label, single-arm study tested a modified Atkins diet (MAD) for 6 months in a group of 20 patients with RRMS with the aim of evaluating the feasibility and safety of the diet. The study reported that, after 6 months of MAD, no subjects had new or enlarging FLAIR/T2 lesions, with significant improvement in EDSS score, Modified Fatigue Impact Scale (MFIS) subscales, and arm function (assessed through the Nine-Hole Peg Test). Similarly, in their phase II study, Brenton and colleagues confirmed their initial findings and described an improvement in depression (Beck Depression Inventory, BDI) and quality of life (Multiple Sclerosis Quality of Life-54, MSQoL -54).

Given this context, a 3-arm parallel-arm randomized controlled pilot study was planned to determine the effectiveness of a modified Atkins diet (MAD) compared to a Mediterranean diet (MedDiet) on quality of life, measured by the physical health subscale (CPH ) of MSQoL -54, in a population with MS followed at the Mondino Foundation Institute of Pavia, Italy. Safety, feasibility and general neurological, nutritional, motor and clinical outcomes were also assessed.

• Study Type: Interventional
• Enrollment (Estimated): 111
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Cinzia Fattore, MD; Phone Number: 0039 0382380385; Email: cinzia.fattore@mondino.it
• Study Contact Backup: Name: Eleonora Tavazzi, MD; Phone Number: 0039 0382380385; Email: eleonora.tavazzi@mondino.it

Study Locations

• Italy
  • Pavia, Italy, 27100
    • Recruiting
    • U.O.Sclerosi Multipla
    • Contact: Cinzia Fattore, MD; Phone Number: 0039 0382380385; Email: cinzia.fattore@mondino.it
    • Contact: Eleonora Tavazzi, MD; Phone Number: 0039 0382380385; Email: eleonora.tavazzi@mondino.it

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Diagnosis of relapsing-remitting MS (RRMS) or progressive MS (PMS)
• Age between 18 and 60 years
• BMI between 18.5 kg/m2 and 39.9 kg/m2
• If on disease-modifying drugs, stable for 6 months, or no use of drugs in the previous 6 months
• Ability to give verbal and written consent

Exclusion Criteria:

• Patients actively engaged in a weight loss program or other specific diet (e.g. vegetarian, vegan); patients not willing to follow the assigned dietary pattern or patients with high adherence to MedDiet (MediLite score > 14)
• Pregnancy or breastfeeding
• Relapse or cortisone treatment within 30 days before study entry
• Clinically relevant metabolic, progressive or malignant diseases
• Intake of > 1 g/day of omega-3 fatty acid supplements
• Underweight (BMI<18.5 kg/m2) or severe obesity
• Significant cognitive-cooperative impairment
• Insulin-dependent diabetes mellitus (type I)
• Weight loss greater than 5 kg within 2 months prior to study entry
• Diagnosis or suspicion of an eating disorder
• Kidney stones
• Oral anticoagulant therapy
• Known alcohol and drug abuse

Telephonic interviews will be performed monthly to evaluate adherence to the dietary treatment and/or whether any changes in supplements use, physical activity, nutrition habits.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Mediterranean Diet; The MedDiet will be planned according to the Mediterranean diet pyramid. Energy prescriptions will be tailored to each patient's specific needs. The initial calorie prescription will be calculated taking into account usual dietary intake REE and physical activity level (PAL). Changes to calorie prescriptions will be made as needed during the course of follow-up. A minimum of 0.8-1 g of animal protein (e.g. eggs, milk, meat, poultry and fish) per kilogram of body weight per day will be given.	Dietary supplement: Mediterranean Diet; The MedDiet will be planned according to the Mediterranean diet pyramid
Experimental: Ketogenic Diet; Modified Atkins diet with a maximum of 20 g of carbohydrates per day. Fat-rich foods of plant origin will be encouraged in order to reach the prescribed daily caloric intake. Energy prescriptions will be tailored on each patient's specific requirements. The initial calorie prescription will be based on an average between the pre-diet intake, REE and physical activity levels. A minimum of 0.8-1 g of protein from animal sources (e.g. eggs, milk, meat, poultry and fish) per kilogram of body weight per day will be given.	Dietary supplement: Ketogenic Diet; Modified Atkins diet with a maximum of 20 g of carbohydrates per day.
Other: Control group; The control group will be asked to continue their dietary and lifestyle habits.	Dietary supplement: Control group; The control group will be asked to continue their dietary and lifestyle habits

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The CPH subscale of the Multiple Sclerosis Quality of Life-54 (MSQoL -54)	Quality of life will be assessed in terms of physical health referring to the CPH subscale of the MSQoL -54 after 6 months of treatment. ITS consists of 52 items grouped in 12 subscales plus two single items. All scores are transformed to scale from 0-100 and then added within each subscale to obtain the subtotal. By dividing the subtotal by the number of responses, the final score of the subscale is obtained. The scores final are in turn multiplied by a specific number at each subscale; adding the scores transformed in this way there is a value for "physical health" and one for "mental health". These two values, added, give the final score of the MSQoL-54. The higher scores demonstrate better HRQoL in patients.	Evaluation at baseline and after 6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Expanded Disability Status Scale (EDSS)	Degree of disability, measured with the EDSS. Scores are based on examination by a neurologist, and climb by half unit increments from 0 to 10 as level of disability increases.They are based on the level of neurological impairment of eight functional systems in the brain: pyramidal, cerebellar, brainstem, sensory, bowel and bladder function, visual function, cerebral functions, other.	Evaluation at baseline and after 6 months
Multiple Sclerosis Functional Composite (MSFC)	It is a 3-part, standardized, quantitative assessment instrument for use in clinical studies, particularly clinical trials, of multiple sclerosis: Timed 25-Foot Walk (T25W) for leg function and ambulation, 9-Hole Peg Test (9HPT) for arm and hand function, and Paced Auditory Serial Addition Test (PASAT-3) for cognitive function. For these instruments there are not the minimum and the maximum values. Execution time is calculated. Longer time corresponds to worse outcome.	Evaluation at baseline and after 6 months
Modified Fatigue Impact Scale (MFIS)	This instrument provides an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. The full-length MFIS consists of 21 items. MFIS total score can range from 0 to 84. MFIS score > 38 indicates moderate to severe fatigue.	Evaluation at baseline and after 6 months
The Pittsburgh Sleep Quality Index	The Pittsburgh Sleep Quality Index (PSQI) is a widely used self-report questionnaire that assesses sleep quality over a one-month time interval. Nineteen individual items generate seven "component" scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The sum of scores for these seven components yields one global score. Pittsburg scale's total score ranges from 0-21; where a higher score describes poorer sleep quality (score >5= inadequate sleep, score <5= adequate sleep)	Evaluation at baseline and after 6 months
The Beck Depression Inventory	The inventory contains 21 self-report items which individuals complete using multiple choice response formats. It is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. BDI score can vary from 0 to 63. A BDI score of < 9 is considered normal, a score of 11-16 mild mood disturbance, and 21-30 mild-moderate depression, >30 severe depression.	Evaluation at baseline and after 6 months

Collaborators and Investigators

• Sponsor: IRCCS National Neurological Institute "C. Mondino" Foundation
• Collaborators: University of Pavia
• Investigators: Principal Investigator: Eleonora Tavazzi, MD, U.O. Sclerosi Multipla

Publications and helpful links

General Publications

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• Choi IY, Piccio L, Childress P, Bollman B, Ghosh A, Brandhorst S, Suarez J, Michalsen A, Cross AH, Morgan TE, Wei M, Paul F, Bock M, Longo VD. A Diet Mimicking Fasting Promotes Regeneration and Reduces Autoimmunity and Multiple Sclerosis Symptoms. Cell Rep. 2016 Jun 7;15(10):2136-2146. doi: 10.1016/j.celrep.2016.05.009. Epub 2016 May 26.
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• Azary S, Schreiner T, Graves J, Waldman A, Belman A, Guttman BW, Aaen G, Tillema JM, Mar S, Hart J, Ness J, Harris Y, Krupp L, Gorman M, Benson L, Rodriguez M, Chitnis T, Rose J, Barcellos LF, Lotze T, Carmichael SL, Roalstad S, Casper CT, Waubant E. Contribution of dietary intake to relapse rate in early paediatric multiple sclerosis. J Neurol Neurosurg Psychiatry. 2018 Jan;89(1):28-33. doi: 10.1136/jnnp-2017-315936. Epub 2017 Oct 9.
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• Brenton JN, Banwell B, Bergqvist AGC, Lehner-Gulotta D, Gampper L, Leytham E, Coleman R, Goldman MD. Pilot study of a ketogenic diet in relapsing-remitting MS. Neurol Neuroimmunol Neuroinflamm. 2019 Apr 12;6(4):e565. doi: 10.1212/NXI.0000000000000565. eCollection 2019 Jul.
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Study record dates

Study Major Dates

• Study Start (Actual): March 15, 2024
• Primary Completion (Estimated): March 15, 2025
• Study Completion (Estimated): September 15, 2025

Study Registration Dates

• First Submitted: November 28, 2024
• First Submitted That Met QC Criteria: November 28, 2024
• First Posted (Actual): December 4, 2024

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: December 18, 2024
• Last Verified: November 1, 2024

More Information

Terms related to this study

• Keywords: Multiple Sclerosis; Mediterranean diet; Ketogenic Dietary Therapy
• Additional Relevant MeSH Terms: Nervous System Diseases; Pathologic Processes; Autoimmune Diseases; Immune System Diseases; Demyelinating Autoimmune Diseases, CNS; Autoimmune Diseases of the Nervous System; Demyelinating Diseases; Multiple Sclerosis; Sclerosis; Multiple Sclerosis, Relapsing-Remitting
• Other Study ID Numbers: KETOMED-MS-2024

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No