Nutritional management of fibromyalgia

Photo Cred: Louis Hansel/Unsplash

By Kellie Blake, RDN, LD, IFNCP

Fibromyalgia syndrome (FMS) is a complex disorder, often with many underlying issues that complicate treatment. Improving gut function, weight, and optimizing nutrient status can significantly improve symptoms, allowing for greater success in the other areas of treatment.

Fibromyalgia is a chronic pain disorder affecting two to eight percent of the adult population. Females are more often affected than males and symptoms include sleep disturbance, soft tissue tender points, musculoskeletal pain, cognitive dysfunction, fatigue, gastrointestinal disturbance, and mood changes. FMS has been found to be comorbid with systemic exertion intolerance disease, functional dyspepsia, interstitial cystitis or bladder pain syndrome, irritable bowel syndrome (IBS), myogenic temporomandibular disorder, myofascial pain syndrome, posttraumatic stress disorder, restless leg syndrome, and tension headache. 

Diagnosis can be difficult as there are no well-established criteria but is typically based on patient complaints and the physical assessment. The etiology of FMS remains unknown, which makes effective treatment a challenge and many FMS sufferers report significant psychological stress related to their symptoms. Those with FMS often have gut, mitochondrial, and adrenal dysfunction, food sensitivities, and micronutrient deficiencies. While there is no specific treatment, a multidisciplinary approach, including nutrition therapy, is generally accepted as the most beneficial option for symptom improvement, including investigating gastrointestinal health, weight, and nutrient status to help guide initial nutrition therapy recommendations.

Seventy percent of FMS clients experience IBS symptoms and many of the same medical nutrition therapy recommendations can be beneficial for both disorders. Addressing increased intestinal permeability and initiating the 5-R protocol for gut restoration can be a powerful initial approach. An elimination food plan for a minimum of four weeks, which restricts gluten, dairy, soy, corn, eggs, inflammatory oils, shellfish, conventionally raised beef, caffeine, soda, black tea, chocolate, alcohol, peanuts, pork, processed meats, and sugar, will remove any items that could be compromising gut health. Concurrent with the elimination diet, replace missing items like digestive enzymes and hydrochloric acid, reinoculate with healthy bacteria, utilize targeted nutrients to repair the gut lining, and educate the client on rebalancing the lifestyle to maintain gut integrity.  If any gastrointestinal symptoms persist once the 5-R protocol has been completed, it may be beneficial to transition the client to a low fermentable oligo-di-mono-saccharide and polyols (FODMAP) diet for several weeks.

One clinical trial as reported in Nutricion Hospitalaria, showed a low FODMAP diet improved somatic and visceral symptoms and also improved weight status of FMS participants. FODMAPs are carbohydrates that are poorly absorbed in the small intestine and fermented in the small or large intestine.  This therapeutic diet is used for two to eight weeks to significantly improve gas, bloating, cramping, pain, diarrhea, and constipation in IBS patients, and has shown positive results for FMS patients as well. This plan can limit dietary fiber intake and nutrient density when used long-term if not well-planned and non-compliance can be an issue. Once the food reintroduction begins, a food plan to optimize mitochondrial function can be one long-term option for FMS patients.

The mitochondria are often affected in those with FMS likely related to the inflammatory process.  Mitochondria are components of cells that use oxygen and nutrients from food to create energy to be used by the body. When mitochondrial function is supported, fatigue, pain, and cognitive issues can improve, healthy muscle mass can be maintained, and excess fat can be reduced. The mitochondrial food plan is anti-inflammatory, low-glycemic, gluten-free, low in grains, and includes high quality fats.    

Obesity is common in those with FMS and both body mass index and body composition have been correlated with increased FMS symptoms and reduced quality of life. Obesity may be implicated in the development of FMS, but also may be a consequence related to the reduced physical activity associated with chronic pain and mental health concerns. The increased risk of metabolic complications related to insulin resistance and the inflammatory process in FMS make targeting weight an important goal. Clients will likely experience weight loss during the elimination food plan and the long-term food plan to support mitochondrial function will continue to improve insulin resistance and metabolic dysfunction.

While there is no clear evidence for specific nutrient supplementation for FMS, optimizing the B vitamins, vitamin D, magnesium, acetyl-l-carnitine, and CoQ10 can be helpful for symptom relief and supporting mitochondrial function. 

B vitamins have a variety of functions in the body, including acting as antioxidants, creating energy from food, carbohydrate, fat, and protein metabolism, DNA production and repair, creating neurotransmitters, and detoxification. The need for B vitamins is increased in those with adrenal dysfunction, which is often present in those with FMS. Supplementing with a B-complex daily can help meet the increased demand.

Vitamin D is a powerful immune and inflammation-modulating hormone and lower levels are associated with a variety of symptoms including chronic pain, depression, and muscle weakness.  A 2017 meta-analysis in the Korean Journal of Pain reported lower vitamin D levels in those with FMS. Optimizing vitamin D to a goal of 50 to 80 ng/mL can potentially improve FMS symptoms.

Magnesium is a co-factor responsible for hundreds of reactions in the body. Inadequate magnesium intake is common with an estimated 68 percent of Americans consuming less than the recommended amount.  As reported in the Journal of Korean Medical Science, lower magnesium levels have been found in those with FMS, so optimizing magnesium intake with food and nutritional supplements may be helpful in improving FMS symptoms.

Acetyl-l-carnitine is a mitochondrial metabolite important for transporting fatty acids into the mitrochondria for energy production and lower levels of acetyl-l-carnitine have been found among those with major depression, which is often found in FMS. Supplementation is potentially beneficial for those with FMS.

CoQ10 is an important antioxidant and necessary for optimal mitochondrial function. As reported in Antioxidant and Redox Signaling, those with FMS have 56 percent lower levels of CoQ10 when compared to healthy controls, therefore supplementation may be considered for FMS patients.

Case Study

I recently had a patient, a 30-year-old female with a diagnosis of fibromyalgia and chronic pain. Her past medical history includes attention deficit hyperactivity disorder, anxiety, urinary tract infections, yeast overgrowth, and migraines. She sought nutrition therapy for improved wellbeing, energy, and strength.  She reported symptoms of balance issues, fatigue, myofascial pain, tingling hands and feet, numbness, constant cold sensation, neck and back pain, dizziness, and migraines, which began when she started college. At one point she was diagnosed with multiple sclerosis, but MRI and lumbar puncture were both negative. Other testing for rheumatoid arthritis, Sjogrens, Lyme disease, and lupus were all negative. She was given the diagnosis of fibromyalgia in 2015. 

My patient avoided gluten, dairy, alcohol, soda, and processed foods, but consumed an extreme amount of coffee. She drank four to six glasses of water per day and reported carbohydrates as comfort foods. She admitted to skipping breakfast due to feeling rushed in the mornings and stated she snacked mostly in the evenings instead of eating dinner due to feeling tired after work. Initial weight was 135 pounds and she had lost 15 pounds over the past year. Her reported usual body was is 120 pounds and she desired to return to that weight. Physical activity was limited due to pain and she reported significant stress related to work and family. She rated her sleep as fair and she admitted to feeling hopeless and discouraged related to her diagnosis and the lack of answers.

Her initial nutrition plan included:

1. Daily stress relief practice: 15 minutes of meditation in both early morning and afternoon
2. Supplements: multivitamin with CoQ10 daily, 200 milligrams of magnesium glycinate before bed, an anti-inflammatory herbal supplement twice per day between meals, adrenal formula between meals, buffered vitamin C 1,000 milligrams per day, methylated B complex one capsule twice per day, and 2,400 milligrams omega-3 per day
3. Salivary cortisol testing related to suspected adrenal dysregulation and her results indicated phase three adrenal dysfunction
4. GI Map stool testing was recommended, but AF declined
5. Restorative yoga daily for 20 minutes
6. Full elimination diet for four weeks
7. 64 ounces of water per day

After four weeks her symptoms had significantly improved and she said she felt much more energetic, but she continued to feel excess stress related to work and family. She lost eight pounds and reported no issues related to the elimination diet, but she did miss coffee and ice cream.

Follow up goals included:

1. Continue all previous goals, but transition to a long-term mitochondrial food plan with at least nine servings of vegetables per day, at least one of those being cruciferous.
2. Six to eight-minute meditation in the car immediately after work due to reported stress when speaking with her family on the drive home from work
3. Consider journaling to help with stress management
4. Chamomile smoothie before bed to promote restful sleep
5. Mocha matcha smoothie in the morning using decaf coffee and continue to avoid regular coffee
6. Avocado ice cream recipe provided as an alternative to regular ice cream

At her final follow up, her weight was down to 113 pounds and she felt more energetic, especially in the evening. While she still struggles with chronic stress, likely the root cause of her FMS, she reports less physical pain and fatigue overall.

References

Cedraschi, C., Girard, E., Piguet, V., Desmeules, J., Allaz, A. (2015) Assessing the Affective Load in the Narratives of Women Suffering From Fibromyalgia: The Clinicians’ Appraisal.  Health Expectations: an international journal of public participation in health care and health policy Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810743/

Kim, YS., Kim, KM., Lee, DJ., Kim, BT., Park, SB., Cho, DY., S, CH., Kim, HA., Park, RW., Joo, NS. (2011) Women with fibromyalgia have lower levels of calcium, magnesium, iron, and manganese in hair mineral analysis. Journal of Korean Medical Science. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3192333/

Makrani, A., Afshari, M., Ghajar, M., Forooghi, Z, & Moosazedeh, M. (2017) Vitamin D and fibromyalgia: a meta-analysis.  Korean Journal of Pain. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5665736/

Marum, A., Moreira, C., Tomas-Carus, P., Saraiva, F., & Guerreiro, C. (2017) A low fermentable oligo-di-mono-saccharides and polyols (FODMAP) diet is a balanced therapy for fibromyalgia with nutritional and symptomatic benefits.  Nutricion Hospitalaria.  Retrieved from: https://www.nutricionhospitalaria.org/index.php/articles/00703/show

Masi, A., and Vincent, A. (2015). A Historical and Clinical Perspective Endorsing Person-Centered Management of Fibromyalgia Syndrome. Current Rheumatology Reviews. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/26088217-a-historical-and-clinical-perspective-endorsing-person-centered-management-of-fibromyalgia-syndrome/

Nasca, C., Bigio, B., Lee, F., Young, S., Kautz, M., Albright, A., Beasley, J., Millington, D., Mathe, A., Kocsis, J., Murrough, J., McEwen, B., Rasgon, N. (2018). Acetyl-l-carnitine Deficiency in Patients with Major Depressive Disorder. Proceedings of the National Academy of Sciences of the United States of America. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112703/