Amyotrophic lateral sclerosis (ALS) continues to be problematic in many ways. Causation remains uncertain, although in genetically heterogeneous populations, there are associations with several DNA mutations in about 10% of patients with ALS. The onset of the disease is difficult to define and the rate of progress is difficult to predict¹; in fact, the disease may commence long before presentation of clinical symptoms.² The role of environmental factors both in triggering onset in patients with sporadic ALS or in genetically susceptible people, and in defining the rate of progress of the disease, have long been contentious.³ Once the diagnosis is established, it is understandable that patients and their caregivers need to know how best to manage the patient and the disease and whether special diets or other interventions might help slow progression of ALS; however, there are few clear answers.