The Wahls Protocol Diet Levels and Food Rules

Table of Contents

1. 1. The Levels of the Wahls Diet
2. 2. What Wahls Says the Diet Is Designed to Do
3. 3. How Her Plan Differs from a Usual Paleo Diet
4. 4. Nine Cups of Vegetables and Fruit in Three Groups
5. 5. Sulfur-Rich Vegetables and Mushrooms
6. 6. Meat, Fish and Organ Meat
7. 7. Seaweed, Algae and Nutritional Yeast
8. 8. Fermented Foods
9. 9. Fats, Oils, Nuts and Sweeteners
10. 10. What the Wahls Elimination Version Leaves Out, and Why
11. 11. Trial Supplements and How Complete the Menus Are
12. Key Research Papers
13. Connections

1. The Levels of the Wahls Diet

Wahls presents her diet as a ladder of levels rather than a single menu. In her books and the cookbook that followed them, the steps are:

• The Wahls Diet — the entry level, high in vegetables and low in grains.
• Wahls Paleo — the next level, which adds organ meat and sea vegetables to the plate.
• Wahls Paleo Plus — a high-fat, ketogenic version, in which the body runs largely on fat and ketones rather than on carbohydrate.

Summaries of The Wahls Protocol Cooking for Life (2017) describe her pointing readers with neurological or severe chronic illness toward the strictest level. Her own website says the cookbook carries recipes for “all levels of the Wahls Diet” and that the later edition of The Wahls Protocol covers “Ketogenic eating and fasting” as well as “a temporary elimination diet to help calm inflammation.”

That elimination diet is the fourth version, the Wahls Elimination diet (her papers abbreviate it WahlsElim). Her 2019 review says the original Wahls diet was “originally developed in 2008” on the tenets of the Paleo diet and her own reading of the literature, and that in 2015 she developed the Elimination version. It is the version tested in her largest trial, WAVES, which compared it with the low-saturated-fat Swank diet in people with relapsing-remitting multiple sclerosis; the trial and its results are described on the randomized diet trials page. An earlier pilot trial compared her modified Paleolithic diet with a ketogenic diet based on medium-chain triglycerides (MCT) from coconut.

Her names for these diets carry trademarks, as she discloses in her papers; the Wahls Elimination diet is the one version her disclosures list as not trademarked.

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2. What Wahls Says the Diet Is Designed to Do

Wahls built her plan around a theory about the nervous system: that nerve cells and the myelin sheath around them need a steady supply of particular nutrients, and that some foods may irritate the immune system. Her team’s 2019 nutrient analysis states the goals in one sentence. The Wahls diet, it says, “was designed to reduce oxidative stress and excitotoxicity, nourish the mitochondria, prevent nutrient deficiencies, minimize food allergies and reduce toxic load, feed the microbiome, activate anti-inflammatory genes and increase nerve growth factors.”

The 2019 review describes the thinking behind the two main versions in its abstract:

“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).”

In plain terms, the first version is about adding: more greens, more sulfur vegetables, more coloured produce, organ meat, seaweed and yeast. The Elimination version keeps all of that and then takes more away, removing the food groups she believes most likely to provoke the immune system or leak through the gut wall. Her reasons for each removal are in section 10.

Wahls ties this nutrient theory to the energy factories inside cells, the mitochondria, which she wrote about in her earlier book; that argument is covered on the Minding My Mitochondria page.

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3. How Her Plan Differs from a Usual Paleo Diet

A Paleolithic, or “Paleo”, diet is built on foods thought to resemble what humans ate before farming: meat, fish, vegetables, fruit, nuts and seeds, without grains, legumes, dairy or refined foods. Randomized studies published before Wahls began her trials had tested Paleolithic eating in other conditions, for example in people with type 2 diabetes.

Her 2019 review lists the ways her original Wahls diet departs from a usual Paleo plan:

• a target of nine or more cups (about 1,950 grams or more) of vegetables and fruit a day, split among leafy, sulfur-rich and deeply coloured groups;
• encouragement of seaweed, algae and nutritional yeast;
• an allowance for limited servings of gluten-free grains such as rice, and of legumes;
• no eggs, which a Paleo diet normally allows;
• less meat and fish than most Paleo plans.

The Elimination version then closes the grain and legume allowance (section 10). So, compared with a typical Paleo menu, the Wahls Elimination plate carries more vegetables, less meat, no eggs, no grains and no legumes, plus a short list of daily “special” foods.

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4. Nine Cups of Vegetables and Fruit in Three Groups

The rule most closely tied to Wahls’s name is the daily target of nine cups of vegetables and fruit, divided into three equal groups. In the WAVES trial rules (2019 review, Table 1), the daily amounts are:

• Dark-green leafy vegetables: 2–3 or more cups a day. Kale is one example; it also counts in the sulfur group.
• Sulfur-rich vegetables: 2–3 or more cups a day — the cabbage family (cruciferous vegetables), the onion and garlic family (alliums) and mushrooms.
• Deeply coloured fruits and vegetables: 2–3 or more cups a day, counted only when the colour runs all the way through the food — the paper’s examples are carrots, beets, sweet potatoes, cherries and berries.

Under the trial rules, white fruits and vegetables count only after those three groups have been met. The review describes dark-green leafy vegetables as excellent sources of vitamin K and of carotenoids, the plant pigments the body can turn into vitamin A, and notes that the plan’s leafy-green servings are greater than the amounts in the U.S. Dietary Guidelines’ healthy eating pattern. Because people differ in how efficiently they convert carotenoids, the review says, the plan also includes ready-made vitamin A from organ meat and cod liver oil (sections 6 and 11).

Her team also ties the produce target to digestion: the review describes non-starchy vegetables, fibre and fermented foods as aimed at one to two soft bowel movements a day, since constipation is common in people with multiple sclerosis.

When her group later analysed what trial participants following the modified Paleolithic diet actually ate, they reported more than nine servings of fruit and vegetables a day.

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5. Sulfur-Rich Vegetables and Mushrooms

The sulfur group is the part of the plan that most sets it apart from general healthy-eating advice. Her 2019 review states that cabbage-family and onion-family vegetables and culinary mushrooms “are rich sources of organic sulfur”, and that sulfur “may protect from neuro inflammation and/or neurodegeneration” and may favourably adjust immune-cell function. The review adds that diets high in sulfur may also lower the risk of heavy-metal toxicity, and that culinary mushrooms have a long history of use as modulators of the immune response.

Examples in this group include broccoli, cabbage, cauliflower, Brussels sprouts, kale (which counts as both leafy and cruciferous), onions, garlic, leeks and mushrooms. The cabbage family is the source of sulforaphane, one of the sulfur compounds most studied in the laboratory; the site’s sulforaphane page covers that research separately.

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6. Meat, Fish and Organ Meat

The Wahls Elimination trial rules set protein foods as follows:

• Meat and fish: 6–12 or more ounces a day.
• Fish rich in omega-3 fats: 16 ounces a week encouraged.
• Organ meat: 12 ounces a week encouraged.

The review gives two reasons for meat and fish. They contain all the essential amino acids, and most other protein sources — grains, legumes, dairy and eggs — are removed on this plan. At the same time the amount is deliberately lower than in most Paleo diets; the review links the lower amount to an aim of reducing activity of the growth-signalling pathways known as mechanistic target of rapamycin (mTOR), insulin and insulin-like growth factor. Grass-fed and grass-finished meats, wild game and wild-caught fish and shellfish are encouraged within each person’s financial means, to raise intake of omega-3 fats.

Organ meat, such as liver and heart, is included as a source of preformed vitamin A (retinol). The review describes organ meat as an excellent source of choline and coenzyme Q10 as well. The site’s organ meats page covers these foods in general.

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7. Seaweed, Algae and Nutritional Yeast

Three small daily additions appear in the trial rules that are rare in other eating plans:

• Seaweed: one serving a day, defined as ¼ teaspoon of dried powder.
• Algae: one serving a day, defined as ½ teaspoon of dried powder.
• Nutritional yeast: one tablespoon a day.

Seaweed is a sea vegetable and a natural source of iodine; the “sea vegetables” are what the Wahls Paleo level adds to the entry level (section 1). The review says nutritional yeast is “encouraged on the WahlsElim diet to boost the B vitamin content of the diet,” and notes that its cheese-like flavour gives people who miss cheese a substitute on a dairy-free plan. The review sums up these extras as foods that provide substances Wahls believes are important for nerve-cell health.

The Swank diet, the comparison diet in her WAVES trial, neither prohibits nor encourages seaweed, algae or nutritional yeast.

The site has separate pages on nutritional yeast and on the sea vegetable sea moss.

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8. Fermented Foods

The trial rules encourage one serving of fermented food a day. The footnote that defines the group lists yogurt, kefir, kombucha, sauerkraut, pickles, kimchi, natto, miso and tempeh, and sets a serving at ¼ cup of fermented vegetable or ½ cup of kombucha tea.

The review’s reasoning is the gut. It describes the regular eating of fermented foods that contain live lactobacillus organisms, and that are made from allowed foods, as encouraged on the Wahls Elimination diet for their potential effect on the gut microbiome. It notes that research reports differences between the gut microbes of people with multiple sclerosis and healthy people, and that diet changes altered gut microbes and disease severity in a mouse model of multiple sclerosis — an animal finding, not a result in patients.

Two parts of the list sit against the plan’s exclusions, and the review reports both as written. The dairy items on the list (yogurt and kefir) and the fermented soybean foods (natto, miso and tempeh) are foods whose plain forms the Elimination plan excludes: its rules leave out cow, goat, mare and soy dairy products and all legumes, soy products included (section 10). The text’s own condition is that fermented foods be “made from allowed foods”; the footnote lists natto, miso and tempeh among its examples without resolving that point further.

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9. Fats, Oils, Nuts and Sweeteners

Unlike the Swank diet, which caps saturated fat at 15 grams a day, the Wahls Elimination plan does not limit total fat. The trial rules read:

• Cooking fats: clarified butter, animal fats, coconut oil and coconut milk as desired for satiety and weight maintenance. Butter itself and trans fats are not allowed.
• Oils: avocado, extra-virgin olive, sesame and sunflower oils as desired; flax, hemp and walnut oils at most 2 tablespoons a day.
• Nuts and seeds: up to 4 ounces a day, soaked and rinsed.
• Sweeteners: no more than 1 teaspoon a day of honey, maple syrup, molasses or sugar.

The review explains several of these choices. The nut limit is set to keep calories from running too high and to keep the ratio of omega-6 to omega-3 fats near 4 to 1. Soaking and sprouting nuts and seeds, a traditional preparation, is described as reducing lectin activity. Canola, corn and soybean oils are left out of the plan to keep the omega-6 to omega-3 ratio near that target, and the review adds solvent extraction as a further reason for leaving out canola oil.

The fat rules matter most at the top level, Wahls Paleo Plus, which is ketogenic: there, fat replaces most of the carbohydrate. The site’s ketogenic diet page covers ketogenic eating in general.

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10. What the Wahls Elimination Version Leaves Out, and Why

The 2019 review states the core of the change in one sentence: “In 2015 Dr. Wahls developed the Wahls Elimination (WahlsElim) diet, eliminating gluten-free grains, legumes and nightshades (e.g., tomatoes, white potatoes, eggplant, peppers and seed spices) to reflect the theoretical benefits of a low lectin diet.” Lectins are proteins found in many plants, especially seeds, grains and beans, that bind to sugars on cell surfaces. The review links lectins to increased intestinal permeability (a “leaky” gut lining) and to activation of innate immune cells.

Under the trial rules, the Elimination version leaves out:

• All grains, including the gluten-free grains such as rice that the original Wahls diet allowed in small servings. Gluten-containing grains were already excluded. Her team’s nutrient analysis says grains and dairy “were excluded because of the potential for undesirable immune effects.” The review also notes that little is known about the effect of grains, or of a gluten-free diet, on MS.
• All legumes — dried beans and peas, green beans, peanuts, soybeans and other soy products. The original Wahls diet allowed limited legume servings; the Elimination version removes them as part of the low-lectin design.
• Dairy: the rules state that cow, goat, mare and soy products are not allowed. The review notes that, with dairy gone, calcium may run low on this diet.
• Eggs. The review says eggs are left out of the Wahls Elimination plan because they are a common food allergen, especially in children, and lists eggs with wheat and milk as common food triggers of eosinophilic esophagitis, an allergic inflammation of the gullet.
• Nightshades — tomato, white potato, eggplant, peppers and spices made from their seeds. Under the trial rules these may be reintroduced one ingredient at a time after three months, and kept if no increase in neurological symptoms follows.
• Butter and trans fats, although clarified butter is allowed (section 9).

The review also discusses ways of lowering lectins in foods: high-pressure cooking denatures lectins in nightshades, grains and legumes, though, it notes, not gluten and possibly not casein, the main milk protein; fermentation is described as another way to reduce lectins. The site’s nightshades page discusses the nightshade question and the Wahls and Swank approaches, and the elimination diet page explains elimination-and-reintroduction plans in general.

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11. Trial Supplements and How Complete the Menus Are

In the WAVES trial, everyone took the same daily supplements, whichever diet they were randomized to, so that supplements would not explain any difference between the diets. The 2019 review lists them:

• cod liver oil, 1 teaspoon;
• a multivitamin and mineral;
• methylfolate, 1,000 micrograms;
• methyl-B12 (methylcobalamin), 1,000 micrograms;
• vitamin D3, 5,000 international units (IU).

These were the trial’s supplements. The site does not prescribe amounts.

Because the Elimination version removes whole food groups, her team checked whether its menus still meet nutrient needs. Their 2019 nutrient-composition paper compared Wahls Elimination menus with the Healthy U.S.-Style Eating Pattern of the U.S. Dietary Guidelines. The menus met nearly all Recommended Dietary Allowances (RDAs); vitamin D and calcium fell below the Recommended Dietary Allowance (RDA) for some age and sex groups. A companion paper did the same analysis for the Swank menus.

A 2020 study by her group then looked at what trial participants actually ate. In people with multiple sclerosis following the modified Paleolithic diet, food intake fell short of needs for vitamin D, choline and calcium, while some participants went above upper intake limits for certain nutrients through supplements. A 2021 analysis of weighed food records from the WAVES trial measured how micronutrient intake changed as participants adopted the Swank and Wahls diets. Her group also published a laboratory method for measuring vitamin K1 and menaquinone-4 (a form of vitamin K2) in blood, applied to one of its clinical studies; leafy greens are a main source of vitamin K1.

In her 2022 review of dietary approaches to MS symptoms, Wahls wrote that “no dietary pattern … has been proven to be effective for reducing the number of relapses or enhancing lesions,” while noting that several pilot studies, including those of her own diet, show reductions in MS-related symptoms. What her trials found is described on the multimodal pilot studies and randomized diet trials pages. To help patients take up the plan, she later set out an 11-principle framework, the Wahls Behavior Change Model, for clinicians.

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Key Research Papers

1. 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(2):352. — PubMed PMID: 30736445
2. 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):537. — PubMed PMID: 30832289
3. Chenard CA, Rubenstein LM, Snetselaar LG, Wahls TL. Nutrient Composition Comparison between the Low Saturated Fat Swank Diet for Multiple Sclerosis and Healthy U.S.-Style Eating Pattern. Nutrients. 2019;11(3):616. — PubMed PMID: 30871265
4. Titcomb TJ, Bisht B, Moore DD 3rd, Chhonker YS, Murry DJ, Snetselaar LG, et al. Eating Pattern and Nutritional Risks among People with Multiple Sclerosis Following a Modified Paleolithic Diet. Nutrients. 2020;12(6):1844. — PubMed PMID: 32575774
5. Titcomb TJ, Brooks L, Smith KL, Ten Eyck P, Rubenstein LM, Wahls TL, et al. 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(10):3507. — PubMed PMID: 34684508
6. Wahls T, Scott MO, Alshare Z, Rubenstein L, Darling W, Carr L, et al. 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(1):309. — PubMed PMID: 29866196
7. Lee JE, Titcomb TJ, Bisht B, Rubenstein LM, Louison R, Wahls TL. A Modified MCT-Based Ketogenic Diet Increases Plasma β-Hydroxybutyrate but Has Less Effect on Fatigue and Quality of Life in People with Multiple Sclerosis Compared to a Modified Paleolithic Diet: A Waitlist-Controlled, Randomized Pilot Study. J Am Coll Nutr. 2021;40(1):13-25. — PubMed PMID: 32213121
8. Wahls TL. Dietary Approaches to Treating Multiple Sclerosis-Related Symptoms. Phys Med Rehabil Clin N Am. 2022;33(3):605-620. — PubMed PMID: 35989054
9. 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. — PubMed PMID: 36110247
10. Zhang Y, Chhonker YS, Bala V, Hagg A, Snetselaar LG, Wahls TL, et al. Reversed phase UPLC/APCI-MS determination of Vitamin K(1) and menaquinone-4 in human plasma: Application to a clinical study. J Pharm Biomed Anal. 2020;183:113147. — PubMed PMID: 32086127
11. Jönsson T, Granfeldt Y, Ahrén B, Branell UC, Pålsson G, Hansson A, et al. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009;8:35. — PubMed PMID: 19604407
12. Scherger JE. The Wahls Protocol. Fam Med. 2017;49(2):149-150. — PubMed PMID: 28218946

PubMed Topic Searches

1. Terry Wahls: diet papers
2. Modified Paleolithic diet and multiple sclerosis
3. Wahls Elimination diet
4. Dietary lectins and intestinal permeability

Further Reading

• Wahls, Chenard and Snetselaar 2019, full text with Table 1 (the Wahls Elimination rules)
• Chenard et al. 2019, full text (Wahls diet history and design goals)
• The Wahls Protocol (2014), University of Iowa catalogue record
• Terry Wahls: books page

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Connections

• Dr. Terry Wahls and the Wahls Protocol
• Terry Wahls: Life and Career
• Minding My Mitochondria: Nutrients for the Brain
• Wahls Multimodal Pilot Studies in Progressive Multiple Sclerosis
• Wahls Diet Randomized Trials in Multiple Sclerosis
• Exercise, Electrical Stimulation and Stress Reduction in the Wahls Protocol
• Terry Wahls: Books and Legacy
• Contemporary Practitioners
• Multiple Sclerosis
• Kale
• Organ Meats
• Elimination Diet

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