insights

IFM educator Terry Wahls, MD, IFMCP, is well known as a clinical researcher and Functional Medicine thought leader, and also as a patient with secondary progressive multiple sclerosis who restored her health using her own diet and lifestyle program called the Wahls Protocol. She is a clinical professor of medicine at the University of Iowa, where she conducts clinical trials using diet and lifestyle treatments to treat autoimmune disorders. In 2018, she was awarded The Institute for Functional Medicine’s Linus Pauling Award for her contributions in research, clinical care, and patient advocacy. She is the author of The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles and just released an updated version of that book, which includes new research on intermittent fasting and how the protocol impacts the microbiome, new recipes, and the new Wahls Elimination Diet bonus plan.

IFM recently interviewed Dr. Wahls about the latest research coming out of her lab and the new additions to the latest version of her book.

Q: Tell us about some of your recent research showing improvements in several parameters for autoimmune patients using the Wahls Protocol. How can Functional Medicine practitioners use this research to help their patients?

Terry Wahls: We have learned a lot from our first three studies and continue to analyze that data. Our first study replicated my interventions: patients with secondary and primary progressive multiple sclerosis (MS) implemented a modified Paleolithic diet, targeted supplements (vitamin D, fish oil, and B vitamins to optimize homocysteine levels), a meditative practice, exercise, and electrical stimulation of muscles. The result was clinically and statistically reduced fatigue,^1,2 improved quality of life, mood,³ and verbal and nonverbal reasoning;⁴ as well as improved motor function in half of the patients.⁴ Half of our patients experienced improved walking and hand function,⁵ which is quite remarkable because progressive MS patients are anticipated to have gait function decline of 10 to 20% each year.

The next study was a randomized wait list–controlled study that compared subjects following the modified Paleolithic diet to subjects following their usual diet. Once again, we found that quality of life and motor function improved with adoption of the Paleolithic diet.⁶ We then compared a ketogenic version of my diet to the original modified Paleolithic diet. The results will be published soon. The current study compared a low saturated fat (Swank) diet to a low lectin version of my diet (Wahls Elimination) in patients with relapsing-remitting MS. We are currently cleaning and analyzing that data, with the goal of presenting our findings at the next major MS research meeting. Our research demonstrates that helping patients improve and optimize their health behaviors can stabilize and even reverse chronic disease.

As most healthcare practitioners know, getting patients to adopt and sustain new diet and health behaviors is incredibly difficult. We are biologically wired to crave salt, sugar, fat, pleasure, comfort, and inactivity, making it very difficult to give up sugar, gluten, casein, and processed foods. Completing the timeline and reviewing patients’ disease course through the Functional Medicine lens helps increase their commitment to adopting a therapeutic diet and lifestyle. We further deepen this commitment by helping patients develop a personal mission statement, reflect on their personal Hero’s journey, and determine what they need to know to make successful changes. I discuss the science of behavior change, food addictions, and motivational interviewing in more detail in my book.

Q: You write about ways to use intermittent fasting effectively and the impact of fasting on ketosis; what should practitioners know that can help their patients get the most benefit out of a diet that includes intermittent fasting?

TW: Ketosis positively impacts cellular function in many ways. However, metabolic switching—switching in and out of ketosis⁷—has even more beneficial impacts on cellular function and brain function than ongoing ketosis. Thus, I have moved most of my patients to metabolic switching, which can be seasonal ketosis, periodic fasting, intermittent fasting, or time-restricted feeding. It is important to collaborate with your patients to determine which approach can be most easily adapted to their daily routines. Finding patterns that can be more readily incorporated increases success rates for patient and family.

Q: What is the Wahls Elimination Diet bonus plan, and how can it help readers pinpoint individual food sensitivities and create a personalized nutrition program?

TW: The Wahls Elimination Diet is a low-lectin version of the various Wahls™ diet plans that I have developed. Lectins are a protein with a sugar side chain that may stimulate an excessive immune response. The patients who are most likely to need the Wahls Elimination diet are those with inflammatory bowel disease and those with an autoimmune process involving their joints, such as rheumatoid arthritis or systemic lupus erythematosus.

There are three levels of the Wahls diet: level one, which can be done as a vegetarian or vegan; level two, which is a paleo version and includes organ meats, fermented foods, and seaweeds; and level three, which is a ketogenic version. The Wahls Elimination Diet can be done for any of the three levels. It removes nightshades (tomatoes, potatoes, eggplants, and peppers), grains, legumes, and seed spices for 100 days and then reintroduces ingredients one at a time. For vegetarians and vegans, we review how to reduce lectins using soaking, sprouting, and/or a pressure cooker. We have completed a detailed nutritional analysis of the Wahls Elimination diet demonstrating that it is comparable or superior to the standard American diet (depending on the nutrient of interest). Details on all diets and modifications are provided in the revised and expanded version of The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles.

Q: Tell us a bit about the latest research on the microbiome and how the Wahls Protocol may impact the microbiome to improve overall health.

TW: Our study team includes an immunologist, microbiologist, and nutritional biochemist. Together, we look closely at how changing the microbiome impacts the clinical function of patients. We are writing grants to fund analyses of biospecimens from prior studies and understand their impact on the metabolome. Clinically, the Wahls Protocol has been very successful with treating and reversing severe constipation typical of MS as well as loose stools typical of inflammatory bowel disease.

Q: Beyond autoimmunity, what other types of conditions has the Wahls Protocol seen success with?

TW: Because I had such success with treating patients in the traumatic brain injury and primary care clinics, I was invited to develop a clinic that was focused on utilizing my Functional Medicine perspective. I invited practitioners in the pain clinic and primary care clinic to send us their most difficult cases, and made sure their patients understood that I would not be using prescription medications. Instead, treatment focused on diet, lifestyle, and health behavior interventions. Patients typically had 10 to 20 active symptoms and diseases and were taking 10 to 30 medications. Disease states included rheumatoid arthritis, systemic lupus erythematosus, myasthenia gravis, polyneuropathy, phantom limb pain (after amputation), heart failure, anxiety, depression, post-traumatic stress disorder, and diabetes (type 1 and type 2).

I did not have access to advanced testing, but I was able to organize the clinic structure, including health behavior psychologists, registered dietitians, and veterans from the therapeutic lifestyle clinic to help teach and explain the protocol. We had great success at reducing pain, reducing fatigue, and reducing brain fog.

Q: What are your plans for future research at the Wahls Research Lab subsequent to the $2 million gift received last year?

TW: We are very excited about this gift, which allows us to work with the departments of neurology and internal medicine to study the impact of a therapeutic diet and lifestyle without disease-modifying drug treatment in patients newly diagnosed with multiple sclerosis and clinically isolated syndrome.

This will be a quasi-experimental study design, meaning it is not randomized. Patients volunteer to be in the intervention arm of study. The control arm will be patients who are being treated by MS neurology specialists. All patients must live within the lower 48 United States and have been diagnosed within the 12 months prior to the initial study visit. Patients who are interested in the study should contact the study team by emailing MSDietStudy@healthcare.uiowa.edu to learn more about the study.

We will prospectively collect measures of walking, vision, cognition, and biomarkers, including brain imaging at baseline and 12 months. We will also collect biospecimens to assess changes in the microbiome, metabolites, and gene expression. And we will collect information about each patient’s timeline and symptom burden in each of the nodes in the matrix.

I am so excited about the progress I have witnessed in the MS research and clinical world, which has become much more receptive to my work. There is a great deal of buzz surrounding my study comparing Swank versus Wahls Elimination diet, whose data we are currently analyzing and plan to present at a major MS research meeting in the next six to twelve months.

Continuing the conversation

Dr. Wahls recently sat down with IFM educator David Haase, MD to continue the conversation and relate some of the research coming out of her lab to current affairs. Watch the full interview below.

References

1. Bisht B, Darling WG, Grossmann RE, et al. A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med. 2014;20(5):347-355. doi:1089/acm.2013.0188
2. Bisht B, Darling WG, Shivapour ET, et al. Multimodal intervention improves fatigue and quality of life in subjects with progressive multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2015;5:19-35. doi:2147/DNND.S76523
3. 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(3):E537. doi:3390/nu11030537
4. Lee JE, Bisht B, Hall MJ, et al. A multimodal, nonpharmacologic intervention improves mood and cognitive function in people with multiple sclerosis. J Am Coll Nutr. 2017;36(3):150-168. doi:1080/07315724.2016.1255160
5. Bisht B, Darling WG, White EC, et al. 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;7:79-93. doi:2147/DNND.S128872
6. Irish AK, Erickson CM, Wahls TL, Snetselaar LG, Darling WG. 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;7:1-18. doi:2147/DNND.S116949
7. Mattson MP, Moehl K, Ghena N, Schmaedick M, Cheng A. Intermittent metabolic switching, neuroplasticity and brain health. Nat Rev Neurosci. 2018;19(2):63-80. doi:1038/nrn.2017.156