Accurate Education - Diet & Fibromyalgia

“It always seems impossible until its done.”
– Nelson Mandela

Diet & Fibromyalgia

The role of diet has been gaining more attention in the past few years along with a growing body of research indicating that in a significant number of fibromyalgia (FM) patients, diet can have an important impact on the severity of symptoms. In some patients, a change in diet can result in a complete resolution of the symptoms associated with FM, while in others, dietary changes may impact pain, fatigue or the “brain fog” of cognitive impairment.

Foods implicated in the symptoms of fibromyalgia include gluten, neuroexcitatory agents such as monosodium glutamate (MSG), and FODMAPs (Fermentable Oligo-Di-Mono-saccharides And Polyols), sugars found in a number of foods. Engaging an Elimination Diet in which suspicious foods are removed from the diet to determine their impact of FM symptoms can identify the culprit foods and potentially lead to a dietary approach that can seriously improve quality of life for some FM patients.

See below for more about diet & fibromyalgia.

See:

For further understanding of FM, also see:

See also:

Antioxidants

NRF2 Activators

and:

Definitions and Terms Related to Pain

Key to Links:

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Diet & Fibromyalgia (FM)

For more information about the characteristic symptoms and features of FM, including conventional assessment and management,

see: Accurate Education – Fibromyalgia

For more information about Complementary and Alteernative Medical (CAM) treatment of FM, including the use of nutraceuticals and supplements along with behavioral approaches,

see: Accurate Education, CAM – Fibromyalgia

Food Intolerance and Sensitivity – Fibromyalgia (FM)

In evaluating which foods may exacerbate symptoms in susceptible individuals with fibromyalgia FM), three food groups are considered to be high risk candidates:

1. FODMAPs (Fermentable Oligo-Di-Mono saccharides And Polyols)

FODMAPS are a group of small chain carbohydrates (sugars and fibers) that are commonly found in everyday foods such as: wheat, barley and rye flours, apples, pears and other fruits, onions, garlic, honey, kidney beans, some nuts and other foods. The impaired ability to digest FODMAPs causes gastrointestinal (GI) symptoms including abdominal cramps, diarrhea, bloating and nausea – symptoms similar to those found in irritable bowel syndrome (IBS).

See: Food Intolerance & Sensitivity – An Overview

2. Gluten

Gluten is a protein found in wheat, rye, and barley. Gluten sensitivity that does not fulfill the diagnostic criteria for Celiac disease (CD), termed non-celiac gluten sensitiviy (NCGS), is increasingly recognized as a frequent and treatable condition with a wide spectrum of manifestations that overlap with the manifestations of FM, including chronic musculoskeletal pain, fatigue, and irritable bowel syndrome. Ingestion of gluten may give rise to a wide range of systemic, behavioral and GI symptoms such as headaches, muscle cramps, bone and joint pain, rashes, fatigue, depression and brain fog as well as abdominal cramps, diarrhea, bloating and nausea.

See Food Intolerance & Hypersensitivity – Gluten

3.Neuroexcitatory Agents – Monosodium Glutamate (MSG) & Aspartame

Monosodium glutamate (MSG), a food additive used as a flavor enhancer, and aspartame, an artificial sweetener, are both thought to possibly induce or exacerbate symptoms in patients with FM.

4.Other Food Sensitivities

Alternative food sensitivities that may co-exist with FM include lactose intolerance and wheat allergy. These conditions are not likely to be confused with or exacerbate FM symptoms and are discussed elsewhere.

See Food Intolerance and Hypersensitivity – An Overview

1. FODMAPs: FM & IBS

Irritable Bowel Syndrome (IBS) is a common gastrointestinal functional disease, characterized by chronic abdominal pain or discomfort, along with diarrhea, constipation (or a pattern of alternation between the two), defecation urgency, severe cramps, bloating and abdominal distension. GI symptoms associated with fibromyalgia (FM) and irritable bowel syndrome (IBS) are often similar and often misdiagnosed. Neither condition is well understood as to their specific causes and treatment of either condition is often unsatisfactory.

It has been found that up to 72% of people with FM also have symptoms of IBS. Alternatively, up to 32% of people with IBS have FM. There is clearly an overlap in these conditions and it is sometimes related to diet. Avoidance of ingesting FODMAPs in both those with IBS as well as those with FM may provide a significant reduction in the GI symptoms common to these two conditions. Up to 75% of those who suffer IBS will benefit from dietary restriction of FODMAPs with improvement of gas, bloating, abdominal pain, and change in bowel habits.

In another study evaluating FM patients with IBS, a one-year gluten-free diet resulted in a 26-29% reduction in FM symptoms. As noted below, some foods (including wheat, barley and rye flours) contain both FODMAPs and gluten.

Testing for FODMAP Intolerance

Unfortunately, there is no specific diagnostic test for FODMAP Intolerance such as a blood test. The only way to determine FODMAP intolerance is to eliminate them from one’s diet and observe for improvement of GI symptoms that subsequently worsen again when FODMAPs are re-introduced back into the diet.

See: Elimination Diet – FODMAPs

Treatment of FODMAP Intolerance

FODMAP intolerance is treated by avoiding ingestion of any offending FODMAPs identified by an elimination diet process. After a period of a few months when symptoms of FODMAP intolerance have resolved by avoiding their ingestion, a retrial may be appropriate by re-introducing previously non-tolerated FODMAPs back into the diet. With the potential return of a healthier gut, FODMAPs may again be tolerated.

See: Elimination Diet – FODMAPs

2. Glutens: FM & Gluten Sensitivity

Ingestion of gluten in sensitive individuals gives rise to a wide range of GI, systemic and/or behavioral symptoms that mimic many of the symptoms experienced by those with fibromyalgia (FM).

Symptoms associated with gluten sensitivity include:

Intestinal
Abdominal pain, cramps

Diarrhea

Nausea

Loss of appetite

Bloating & flatulence

Skin

Erythema (redness)

Eczema

Oral sores

General/Systemic

Headaches

Bone and joint pain

Muscle cramps and contractions

Numbness in hands and feet (small fiber neuropathy – SFN)

Chronic fatigue

Osteopenia or osteoporosis

Elevated liver enzyme tests (ALT, AST) which may resolve with a gluten-free diet (GFD).

Vitamin deficiencies (B12, B9-folate, carotene)

Mineral Deficiencies (calcium, iron)

Behavioral

Attention deficit (“Brain Fog”)

Depression

Irritability

Hyperactivity

Types of Gluten Sensitivity

Gluten sensitivity falls into two categories: Celiac disease (CeD), an autoimmune disorder; and non-celiac gluten sensitivity (NCGS), a poorly defined condition related to multiple, different underlying factors. While the co-existence of both CeD and FM in the same person is fairly rare, the co-existence of both NCGS and FM is not uncommon.

For more information about gluten, CeD and NCGS:

See Food Intolerance & Hypersensitivity – Gluten

Testing for Gluten Sensitivity

Testing for gluten sensitivity includes screening for CeD with blood tests followed by intestinal biopsy in those with high risk for CeD. Those identified as low risk for CeD based on blood tests and/or biopsy are then considered for NCGS and a trial gluten-free or elimination diet is advised.

For more information about diagnostic testing for gluten hypersensitivity and CeD,

See Food Intolerance & Hypersensitivity – Gluten

FM and a Gluten-free Diet

There are a limited number of studies that have evaluated gluten-free diets in fibromyalgia patients. A 2013 study of FM patients with CeD reported an improvement of both their FM symptoms as well as their CeD symptoms with a gluten-free diet (GFD). Although it is not clear how some FM patients develop NCGS, some studies show that some FM patients without CeD respond to a gluten-free diet with significant improvement of both GI and systemic symptoms.

In another 2013 study, twenty patients with fibromyalgia without CeD were placed on a gluten-free diet and monitored over a period of 5-31 months (median 16 months). A “significant clinical response” of FM symptoms was defined as achieving at least one of the following: marked reduction of FM pain, return to work, return to normal life, or the discontinuation of opioids.

In this study, all patients experienced a “significant clinical response,” and their level of widespread chronic pain improved dramatically; for 15 patients, chronic widespread pain was no longer present, consistent with remission of FM. Fifteen patients returned to work or normal life. In three patients who had been previously treated with opioids, the opioids were successfully discontinued. Fatigue, GI symptoms, migraine, and depression also improved together with pain. Two patients, both with oral ulcers, went into complete remission of their psoriatic arthritis and nonspecific spine arthritis.

For some patients in this study, the clinical improvement after starting the gluten-free diet (GFD) was striking and observed within only a few months; for other patients, improvement was very slow and was gradually observed ov
er many months of follow-up. For eight patients, the return to eating gluten was followed by clinical worsening, which then subsided again after returning to a strict GFD. A significant limitation of this study, however, was it’s small size of only twenty patients. Additional, larger studies will be necessary to confirm the validity of these results.

In yet another study evaluating a 24-week gluten-free diet (GFD) in FM patients, there was a 37-54% reduction in severity of FM symptoms. Interestingly, this study also found a similar reduction of symptom severity with a 24-week reduced-calorie diet (1500 cal/day). These studies suggest that non-celiac gluten sensitivity may be an underlying contributor to symptoms of FM.

Treatment of NCGS in Fibromyalgia

For those with NCGS and mild to moderate gluten sensitivity, small amounts of gluten exposure may be tolerated. Each individual needs to determine their own regimen of foods and quantities that are allowable. Since the causes of NCGS are not well understood, treatment of NCGS may respond differently with different people. Given that the microbiome may be a factor in NCGS, there may be a role for the use of pre- and probiotics in the management of NCGS symptoms. Also since a leaky gut may also play a role in NCGS, evaluation and management of leaky gut should be considered in treating NCGS.

That being said, the starting point of treatment for those with FM and NCGS should include a completely GFD. After a period of a few months when symptoms of NCGS have resolved by avoiding gluten ingestion, a retrial may be appropriate by re-introducing gluten back into the diet. With the potential return of a healthier gut, gluten may again be tolerated.

3.Neuroexcitatory Agents – Aspartame & Monosodium Glutamate (MSG)

Neuroexcitatory agents, or excitotoxins, are molecules such as aspartame and monosodium glutamate (MSG) that act as excitatory neurotransmitters which can lead to neurotoxicity when used in excess. A growing number of reports appear to identify a subset of fibromyalgia patients whose symptoms are induced or exacerbated by excitotoxins. An alternative explanation may also be that there exists an “excitotoxin syndrome” that is similar to fibromyalgia and may be mistakenly diagnosed as fibromyalgia.

Perhaps the earliest report in 2001 described four women that had complete, or nearly complete, resolution of their fibromyalgia symptoms within months after eliminating monosodium glutamate (MSG) or MSG plus aspartame from their diet. These symptoms included widespread pain, fatigue and brain fog/cognitive impairment. Upon reinstitution of these agents, the symptoms returned and then, upon removal again of these agents, the symptoms again resolved.

Monosodium Glutamate (MS)

MSG, the sodium salt of the amino acid glutamic acid or glutamate, is an additive used to enhance the flavor of certain foods. It does not have a flavor of its own, but it is believed to enhance the taste of other foods by stimulating glutamate receptors on the tongue. In 1959 MSG was classified by the Food and Drug Administration (FDA) as a “generally recognized as safe” (GRAS) substance. MSG is commonly found in processed food, appearing under many names, including gelatin, hydrolyzed vegetable protein, textured protein, and yeast extract.

In the 1980’s multiple reports surfaced describing a multitude of symptoms associated with ingesting MSG including headache, weakness, muscle tightness, numbness or tingling, and flushing. Collectively, these symptoms hcame to be referred to as the “MSG Syndrome.”

While the majority of people do not appear particularly sensitive to MSG or susceptible to the MSG syndrome, a minority may be intolerant of MSG when the substance is eaten in large quantities. One group of susceptible people may be patients with severe, poorly controlled asthma, whose asthma may worsen if they eat food containing MSG.

A second group of susceptible people may be patients with fibromyalgia (FM) whose symptoms may be aggravated by exposure to ingested MSG. A 2012 study evaluated fifty-seven FM patients who also had irritable bowel syndrome (IBS) that were placed on a 4-week diet that excluded dietary additive excitotoxins including MSG and aspartame. 84% of the participanrs reported that at least 30% of their symptoms resolved.

Aspartame

First introduced in 1981, aspartame is a dipeptide of aspartate and phenylalanine and is the dominant artificial sweetener on the market, used in foods, beverages, and drugs. Aspartame is hydrolyzed in the gut to aspartate which has neurotoxic effects that are additive when combined with MSG.

Cases have been reported in which removal of aspartame from the diet results in dramatic relief of symptoms related to fibromyalgia (FM), including fatigue and pain. Aspartame is a potent flavoring agent and calorie-saving sugar substitute which is a widely used in drugs, beverages, foods as a synthetic non-nutritive sweetener.

In one case it was calculated that a patient had been ingesting about 60mg/day of aspartame for 10 years and when the aspartame was discontinued the patient’s FM symptoms disappeared. Even after three years of aspartame abstinence the FM symptoms never recurred. Another case report involving an individual ingesting about 120mg/day of aspartame for three years chad complete regression of his FM pain with discontinuation of aspartame. After two years of aspartame abstinence the FM symptoms never recurred.

Testing for Aspartame Sensitivity

Since there is no specific test for aspartame sensitivity, the diagnosis can only be established by removing it from the diet for 3-4 weeks and monitor for improvement or resolution of FM possibly to be attributed to ingestion of aspartame.

Conclusion

A trial elimination of MSG and aspartame from the diets of patients with fibromyalgia may offers a simple, benign treatment option with the potential for dramatic improvements in a subset of patients.

W
ho Should Do a Trial of an Elimination Diet?

Since FODMAP intolerance generally results in symptoms limited to the GI tract, it would be argued that only patients with significant impact of GI symptoms consider a FODMAP-free diet. Thus, those with GI complaints that are frequent, chronically recurrent and that may include abdominal bloating, flatulence, cramps, abdominal pain, diarrhea, constipation, nausea, or loss of appetite should consider a 3-4 week elimination diet to identify if eliminating these foods results in a reduction of the GI symptoms suffered.

Since gluten hypersensitivity that is a result of Celiac disease (CeD) has a known auto-immune basis, anyone with blood tests and/or intestinal biopsy findings consistent with CeD should absolutely do an extended trial of a gluten-free diet (GFD). It may takes weeks or even up to a year to experience the full benefit of the GFD in those with CeD. Blood tests can be performed to monitor antibody levels to track an individual’s response.

At present, there are no defined predictors of response to a gluten-free diet in patients with symptoms of IBS or non-celiac gluten sensitivity (NCGS). Furthermore, there is no diagnostic marker for NCGS and the diagnosis is confirmed only when symptoms improve with a gluten-free diet and symptoms reappear with addition of gluten back into the diet. Therefore, for those with FM who test negative for CeD, there is no specific test that can otherwise be performed to determine if gluten hypersensitivity is contributing to symptoms attributed to FM, including both systemic and/or gastroeintestional.

For this reason, it is advisable that anyone with FM symptoms that significantly impacts their quality of life, likely most everyone with FM, should consider a trial of a GFD for 3-4 weeks. If there is no significant benefit achieved with a trial GFD, the question of possible gluten hypersensitivity as a contributor to one’s symptoms is excluded.

Elimination Diet For Fibromyalgia

As noted above, ingestion of multiple food groups may be responsible for, or exacerbate many of the symptoms of fibromyalgia particularly glutens, FODMAPs and excitotoxins.. Also, given the overlap in foods that may contain these elements, an elimination diet for most people with FM should be considered. For those with FM but no GI symptoms, a 4 week trial eliimnating glutens and excitotoxins should be intitiated. If GI symptoms are also present, FODMAPs should be eliminated as well during the trial.

Eliminate Glutens

If the celiac-specific blood tests are negative in symptomatic patients, a positive IgA-AGA (anti-gliadin antibody test) is suggestive but not diagnostic of NCGS and a trial of a gluten-free diet (GFD) is strongly advised. Since the diagnosis of NCGS is compromised by the lack of a reliable diagnostic test, in order to identify NCGS once the diagnosis of CeD is excluded, dietary elimination of gluten to observe for improvement of symptoms is advised. An improvement in symptoms while on a GFD would support the diagnosis of NCGS/wheat hypersensitivity.

See: Elimination Diet – Gluten

Eliminate FODMAPs

Those with GI symptoms described above, especially those already diagnosed with IBS and FM, should consider a 4 week diet eliminating FODMAPs. Additionally, IBS symptoms may be similar and difficult to distinguish from gluten sensitivity. In fact, these two conditions may coexist in the same person. Studies indicate that about 50% of those with IBS have improvement of symptoms with a gluten-free diet, compared with 75% who improve with a FODMAP-free diet. Therefore, for FM patients with symptoms consistent with IBS, a 3-4 week trial of dietary elimination of both gluten and FODMAPs to observe for improvement of symptoms is advised, once the diagnosis of CeD is excluded.

See: Elimination Diet – FODMAPs

References:

FM & CAM – Overview

FM & Diet – Overviews

FM & Diet – Microbiome

Altered microbiome composition in individuals with fibromyalgia – 2019

FM & Diet – Excitotoxins: Aspartame & MSG (glutamate)

FM & Diet – FODMAPs

**FM & Diet – FM and Irritable Bowel Syndrome (IBS)**

FM & Diet – Gluten: FM and Celiac Di
sease

Clinical impact of a gluten-free diet on health-related quality of life in seven fibromyalgia syndrome patients with associated celiac disease

FM & Diet – Gluten: Non-Celiac Gluten Sensitivity (NCGS)

FM & Diet – Obesity

Fibromyalgia and obesity: the hidden link. – PubMed – NCBI

FM – Genetics

CAM, FMS – Oxidative Stress

CAM, FMS – Mitochondrial Dysfunction

CAM, FMS – Treatment (Tx)

FM – Antioxidants & NRF2 Activators

(See also: Antioxidants and NRF2 Activators)

Fibromyalgia, Oxidative Stress and NRF2 – Any Hope

FM – Antioxidants: CoQ10

FM – Antioxidants & NRF2 Activators: Curcumin

Therapeutic roles of curcumin – lessons learned from clinical trials. – 2013

FM – Antioxidants: Luteolin

FM – Vitamin D

Emphasis on Education

Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through
discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.

For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.

Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.

For more information, please contact Accurate Clinic.

Supplements recommended by Dr. Ehlenberger may be purchased commercially online or at Accurate Clinic.

Please read about our statement regarding the sale of products recommended by Dr. Ehlenberger.

Accurate Education – Diet & Fibromyalgia

Diet & Fibromyalgia

Key to Links:

Diet & Fibromyalgia (FM)

Food Intolerance and Sensitivity – Fibromyalgia (FM)

1. FODMAPs: FM & IBS

2. Glutens: FM & Gluten Sensitivity

FM and a Gluten-free Diet

Treatment of NCGS in Fibromyalgia

3.Neuroexcitatory Agents – Aspartame & Monosodium Glutamate (MSG)

W
ho Should Do a Trial of an Elimination Diet?

Elimination Diet For Fibromyalgia

References:

FM & CAM – Overview

FM & Diet – Overviews

FM & Diet – Microbiome

FM & Diet – Excitotoxins: Aspartame & MSG (glutamate)

FM & Diet – FODMAPs

**FM & Diet – FM and Irritable Bowel Syndrome (IBS)**

FM & Diet – Gluten: FM and Celiac Di
sease

FM & Diet – Gluten: Non-Celiac Gluten Sensitivity (NCGS)

FM & Diet – Obesity

FM – Genetics

FM – Genetics: COMT

FM – Genetics, COMT Inhibitors: Quercetin

FM- Genetics, COMT Inhibitors: Green Tea

CAM, FMS – Oxidative Stress

CAM, FMS – Mitochondrial Dysfunction

CAM, FMS – Treatment (Tx)

FM – Antioxidants & NRF2 Activators

FM – Antioxidants: CoQ10

FM – Antioxidants & NRF2 Activators: Curcumin

FM – Antioxidants: Luteolin

FM – Vitamin D

Emphasis on Education

For more information, please contact Accurate Clinic.

Accurate Supplement Prices

Diet & Fibromyalgia

Key to Links:

Diet & Fibromyalgia (FM)

Food Intolerance and Sensitivity – Fibromyalgia (FM)

1. FODMAPs: FM & IBS

2. Glutens: FM & Gluten Sensitivity

FM and a Gluten-free Diet

Treatment of NCGS in Fibromyalgia

3.Neuroexcitatory Agents – Aspartame & Monosodium Glutamate (MSG)

W ho Should Do a Trial of an Elimination Diet?

Elimination Diet For Fibromyalgia

References:

FM & CAM – Overview

FM & Diet – Overviews

FM & Diet – Microbiome

FM & Diet – Excitotoxins: Aspartame & MSG (glutamate)

FM & Diet – FODMAPs

FM & Diet – FM and Irritable Bowel Syndrome (IBS)

FM & Diet – Gluten: FM and Celiac Di sease

FM & Diet – Gluten: Non-Celiac Gluten Sensitivity (NCGS)

FM & Diet – Obesity

FM – Genetics

FM – Genetics: COMT

FM – Genetics, COMT Inhibitors: Quercetin

FM- Genetics, COMT Inhibitors: Green Tea

CAM, FMS – Oxidative Stress

CAM, FMS – Mitochondrial Dysfunction

CAM, FMS – Treatment (Tx)

FM – Antioxidants & NRF2 Activators

FM – Antioxidants: CoQ10

FM – Antioxidants & NRF2 Activators: Curcumin

FM – Antioxidants: Luteolin

FM – Vitamin D

Emphasis on Education

For more information, please contact Accurate Clinic.

Accurate Supplement Prices

W
ho Should Do a Trial of an Elimination Diet?

**FM & Diet – FM and Irritable Bowel Syndrome (IBS)**

FM & Diet – Gluten: FM and Celiac Di
sease