Fibromyalgia (FM) is a complex multifactorial syndrome characterized by widespread chronic pain accompanied by a constellation of somatic and psychological manifestations. These manifestations include fatigue, joint stiffness, sleep disorders, depression, anxiety, gastrointestinal and cognitive disorders. FM can occur at any age with a prevalence of 2-8% in the general adult population, and is more common in women than men, with a ratio of 2:1. Optimal management of FM requires a timely diagnosis, together with a comprehensive assessment of pain, function and psychosocial context. Experts recommend nonpharmacological therapy as a first-line strategy, with the pharmacological option to be chosen only in case of lack of effect. Among the nonpharmacological treatment options, nutrition has shown increasing interest in the literature in recent years. This article aims to summarise the possible relationship between FM and nutrition, exploring the role of nutrients, foods and dietary patterns in FM syndrome, with a focus on the Mediterranean diet.
The Role of Nutrition in Fibromyalgia Management
The management of FM requires a multidisciplinary approach combining both pharmacological and nonpharmacological strategies. Among nonpharmacological strategies, growing evidence suggests a potential beneficial role for nutrition. An imbalance of dietary components, including minerals and vitamins, can play a critical role in the development of FM. A survey conducted by Arranz and colleagues revealed that 73% of the subjects affected by FM are users of nutritional supplements, and 61% of these became users after the onset of the disease.
Dietary Supplements: A Controversial Role
Analysis of the literature has shown that the role of dietary supplements remains controversial, although clinical trials with vitamin D, magnesium, iron and probiotics’ supplementation show promising results.
Vitamin D
Some evidence suggests that vitamin D supplementation should be considered in the management of FM in light of the fact that about 40% of FM subjects have been reported with vitamin D deficiency. In addition, several studies have suggested an association between low serum vitamin D levels and chronic pain, depression and anxiety in FM patients.
The first study investigating the effect of vitamin D supplementation on FM subjects was conducted by Arnold and colleagues in 2008. Ninety FM patients with mild to moderate vitamin D deficiency were randomly assigned to receive 50,000 units of cholecalciferol (vitamin D3) per week compared with a placebo. After 8 weeks of intervention, the treated group showed a significant improvement in FM scores, in contrast to the placebo group. Subsequently, other studies were performed to evaluate the effect of vitamin D supplementation in FM patients. Although in a limited sample of participants, all of these studies reported a beneficial effect of vitamin D supplementation. However, all authors stressed the importance of testing serum vitamin D levels and recommend supplementation when risk factors for vitamin D deficiency are present.
Read also: A Review of the Mediterranean Diet in Kidney Disease
Antioxidant Vitamins (C and E)
Antioxidant vitamins such as vitamin C and vitamin E can play a beneficial role in the management of certain typical symptoms of FM, since they are useful for preserving the cerebellar functions, memory, emotive responses as well as muscle function. However, there are currently no consistent studies in the literature.
A recent meta-analysis reported lower levels of vitamin E in FM patients than in healthy controls, although this difference disappeared when low quality studies were excluded from the analysis. In addition, treatment with vitamin C and E combined with or without exercise compared to exercise only in 32 women with FM over a 12 week period did not show a statistically significant improvement in FM symptoms, although both interventions resulted in significantly higher serum levels of vitamin A, C and E.
Magnesium
Regarding the mineral status, several studies have shown a decrease in intracellular magnesium content in FM patients. Magnesium deficiencies were largely associated with low-grade inflammation, muscle weakness and paresthesia, which are typical symptoms of FM. A recent study has shown that low dietary magnesium intake is correlated with worsening pain threshold parameters in FM patients. Magnesium has always been considered the nonpharmacological supplement with the highest potential for FM; however, so far, only two clinical trials have been performed in FM patients.
The first study investigating the effect of magnesium combined with malic acid supplementation was performed in 1995 by Russell and colleagues, showing little or no effect on pain or depression in 24 women with FM when using low doses of supplementation. However, with increased dose and a longer duration of treatment, a significant improvement in pain and tenderness was reported. The second study tested the effect of treatment with magnesium citrate in combination with amitriptyline versus amitriptyline in 60 female FM subjects, showing that amitriptyline and magnesium supplementation were more effective in all measured outcomes than amitriptyline alone. Improvement in TPC, FIQ and BDI with the Mg citrate treatment.
Iron
With regard to other minerals, some studies indicated a potential link between iron deficiency and FM. However, only one study evaluated the effect of iron supplementation on FM symptoms, fatigue and iron status of 81 FM subjects, showing an overall improvement only in the treated group.
Read also: Delicious Mediterranean Recipes
Probiotics
Increasing evidence suggests that FM patients may present altered microbiota, with the abundance of different taxa selectively correlated with disease-related symptoms. This has led researchers to hypothesize a potential beneficial use of probiotics in the treatment of FM. A pilot study to investigate the effect of a 7 week supplementation with a multispecies probiotic showed improved cognition, particularly impulsive choice and decision-making, in 40 subjects diagnosed with FM. On the other hand, no other beneficial effects were observed in self-reported pain, quality of life, depression or anxiety.
Amino Acids and Other Supplements
Several studies have reported an association between amino acid deficiencies such as valine, leucine, isoleucine and tryptophan and FM symptoms. However, to date, no intervention studies have been carried out to test the effect of a supplementation with these elements. Furthermore, some studies have reported some potential benefits in FM patients from botanical or antioxidant supplements, although the evidence to support these substances is very weak. Several nutritional supplements such as Chlorella pyreinoidosa, cellfood, coenzyme Q10, Ginkgo biloba, ascorbigen, L-carnitine, S-adenosylmethionine, creatine and melatonin have shown some benefits for FM patients, improving symptoms such as muscle pain, fatigue, morning stiffness and quality of life. Although patients frequently experience several positive effects from supplementations, there is insufficient evidence to recommend their use in the clinical practice.
Dietary Interventions and Fibromyalgia Symptoms
With regard to dietary interventions, the administration of olive oil, the replacement diet with ancient grains, low-calorie diets, the low FODMAPs diet, the gluten-free diet, the monosodium glutamate and aspartame-free diet, vegetarian diets as well as the Mediterranean diet all appear to be effective in reducing the FM symptoms.
The Mediterranean Diet: A Promising Approach
Among dietary interventions, the Mediterranean diet stands out as a promising approach. The Mediterranean diet is believed to have an anti-inflammatory effect on the body. As fibromyalgia symptoms may be exacerbated by inflammation, investigators sought to evaluate the potential beneficial effects of this diet among this patient population. The Mediterranean diet consists of 3 meals and 2 snacks per day for 4 weeks. Patients were to receive 50% of their energy intake from complex carbohydrates with limited sugar and sweeteners; 30% from fats with an adequate intake of polyunsaturated fatty acids from foods like fish, nuts, and extra virgin olive oil; and 20% from protein. They were also required to have ≥ 20 g of fiber from fruits, vegetables, and starches. Milk and dairy products were not permitted during the study period. Patients in the Mediterranean diet group reported improvements in most fibromyalgia measures, including anxiety, fatigue, and disability scores.
The Mediterranean diet is quite popular generally, not just among people with fibromyalgia, and with good reason. It emphasizes nutrient-rich foods and has been shown to reduce the risk of cancer and cardiovascular disease. Research also suggests that it may also help improve fatigue, sleep problems, anxiety, and depression associated with fibromyalgia specifically. This study investigated the Mediterranean diet alone or combined with tryptophan and magnesium supplementation, and found that the diet plus supplementation was associated with the greatest improvements.
Read also: Mediterranean Diet, Instant Pot Style
Key Components of the Mediterranean Diet
This approach to eating is based on traditional diets of people in the Mediterranean region. It includes plenty of vegetables and fruit; whole grains rather than refined flour, such as that in white bread and pasta; beans, low-fat dairy, cold-water fish (which is high in beneficial omega-3 fatty acids and vitamin D), and poultry as protein sources, with minimal red meat; and olive oil as the main source of fat. It’s naturally low in cholesterol and high in antioxidants, which help reduce inflammation. This may explain why it seems to be protective against cancer and ease fibromyalgia symptoms.
Personalized Mediterranean Diet: A Clinical Trial
A randomized controlled trial focused on the possibility of improving the quality of life of patients with fibromyalgia by changing their dietary habits. The patients signed an informed consent form. The inclusion criteria were: diagnosis of FM according to the 2016 American College of Rheumatology (ACR) criteria, which recommends the use of the widespread pain index (WPI) and the symptoms severity scale (SS); age between 18 and 65 years; and the persistence of diffuse pain and symptoms of FM despite the taking of medication in the 3 months prior to inclusion in the study. In the DIET group, the daily intake of nutrients was based on the pattern of the Mediterranean diet. This version of the Mediterranean diet, in which dairy products and eggs were excluded, was used to achieve a greater impact of the diet on the patient’s habits.
The eating attitude test (EAT), which indicates the presence of an eating disorder, consists of 26 questions to which the respondent can answer: always (3), usually (2), often (1), sometimes (0), rarely (0), or never (0). The brief pain inventory (BPI) measures both the intensity of pain and how much the pain interferes with the patient’s life. It also asks the patient about pain relief, pain quality and the patient’s perception of the cause of the pain. The numeric rating scale (NRS) for pain is a unidimensional measure of pain intensity in adults. The self-rating anxiety scale (SAS) introduced by Zung is frequently used in research and clinical practice to assess anxiety. The multidimensional assessment of fatigue (MAF) scale is a self-administered survey that provides a global fatigue index. The fibromyalgia impact questionnaire (FIQ) is a fibromyalgia-specific outcome instrument designed to assess health status, progress and outcomes in patients with fibromyalgia.
The patients who adhered to the anti-inflammatory diet (DIET group) reported significant improvements in most of the parameters of interest compared with the NODIET group, whose parameters remained stable. While the WPI and SS parameters remained stable, significant effects were recorded for the other measures. The comparison of the DIET group’s values at the three visits revealed significant differences in all scales: pain-related disability, impairment of motor activity, impairment of work activity, pain severity, and global index of severity. The effect became significant at visit 3, as shown by the analysis of the NRS in the DIET group. The scores for the DIET group were lower at visit 2 than at visit 1 and were lower than the NODIET group at visit 2 for the self-rating anxiety scale (SAS) scores and self-rating depression scale (SDS) scores. The scores obtained in the DIET group were lower at visit 2 than at visit 1 and were lower than the NODIET group at visit 2 for the multidimensional assessment of fatigue (MAF) scores. The DIET group scores were lower at visit 2 than at visit 1, the NODIET group values were higher at visit 2 than at visit 1, and at visit 2 the DIET group had lower values than the NODIET group for the fibromyalgia impact questionnaire (FIQ) scores.
The group of patients receiving the personalized Mediterranean diet already improved in many parameters after one month and most of them also showed better results at the end of the second month. The presence of gut function alterations can explain these conditions. Possible mechanisms of action behind the health benefits of dietary manipulation and the elimination of possible offending foods, may include significant changes in intestinal microbiota, highly sensitive to food nature.
Other Dietary Approaches
Besides the Mediterranean diet, other dietary approaches have shown potential in alleviating FM symptoms.
Extra-Virgin Olive Oil (EVOO)
Extra-virgin olive oil (EVOO) is characterized by a high concentration of phenolic compounds. A clinical trial investigated the effect of 50 mL/die of EVOO compared to refined olive oil in 23 female FM subjects. After 3 weeks of intervention, the authors reported a statistically significant improvement in protein carbonylation, lipid peroxidation, FIQ and mental health status after the intervention with EVOO. Recently, the same research group reported similar beneficial effects of EVOO on several cardiovascular risk markers of 30 FM women, concluding that EVOO can protect women with FM against cardiovascular disease, thus proving to be a valuable therapeutic support in patients with FM.
Ancient Grains
In recent years, interest in ancient grains such as Khorasan wheat has been steadily increasing due to their beneficial effect on various pathological conditions. The positive effect on health status seems to be due to the higher content of macro- and microelements, in particular magnesium, phosphorus, potassium, selenium and zinc, as well as carotenoids and polyphenols, compared to modern wheat. Our group recently studied the effect of a replacement diet with cereal products based on ancient Khorasan wheat compared to the modern variety “Palesio” on the symptoms and quality of life of 20 patients with FM. After 8 weeks, participants reported an overall improvement in the severity of FM-related symptoms, including widespread self-reported body pain, daytime sleepiness, fatigue and tiredness, resulting in an improvement in the impact of the disease on daily activities, with a greater positive effect after the intervention with Khorasan.
Elimination Diets: MSG and Aspartame-Free
Monosodium glutamate (MSG) and aspartame may act as excitotoxin molecules in organisms, acting as excitatory neurotransmitters, and may lead to neurotoxicity if used in excess. Two case series on a total of 6 FM patients reported an overall improvement in FM symptoms such as chronic pain, fatigue, sleep and cognitive function after several months of aspartame-free or MSG plus aspartame-free diet. A 30% remission of symptoms after an excitotoxin elimination diet was also observed in a sample of 46 patients with FM and irritable bowel syndrome (IBS). Interestingly, the MSG challenge led to a significant return of symptoms, a worsening of FM severity and a decrease in quality of life in almost all patients. On the other hand, a total of 36 women with FM reported no significant differences in pain after a 12 week elimination of dietary MSG and aspartame, suggesting that discontinuation of dietary MSG and aspartame did not improve the symptoms of FM.
Gluten-Free Diet
FM patients often have gastrointestinal symptoms that significantly overlap with various gluten-related disorders such as nausea, abdominal pain, fatigue, tiredness, chronic pain and mood disturbance, suggesting a possible coexistence of noncoeliac gluten sensitivity in such patients. This has led many investigators to hypothesize that a gluten-free diet could be beneficial for patients with FM. A pilot study investigating the clinical impact of a 1 year gluten-free diet in a small sample of 7 patients with coeliac disease, IBS and FM, revealed an overall improvement of pain symptoms, quality of life, cognitive function as well as of tissue transglutaminase serum levels. The same research group investigated the effect of a 1 year gluten-free diet on 97 women with FM and IBS with or without lymphocytic enteritis, showing a slight but significant improvement in both IBS-related symptoms (chronic abdominal pain, changes in intestinal habit, bloating) and FM-related symptoms (chronic widespread pain, generalized tender points, fatigue and restless sleep) in the subgroup of lymphocytic enteritis. Similar results were obtained in a 16.4 month gluten-free intervention on 20 FM patients without coeliac disease.
General Dietary Recommendations for Fibromyalgia
Regardless of the specific diet, some general dietary recommendations can be beneficial for individuals with fibromyalgia.
Anti-Inflammatory Diet
There is evidence to suggest that adopting an anti-inflammatory diet can help people with chronic pain. An anti-inflammatory diet is not a specific eating plan, but its guidelines can help people make suitable choices. Typically, an anti-inflammatory diet is defined as one that includes eight to nine servings of vegetables per day (two of which could be fruit), minimal or no dairy products, whole grains instead of refined flours, and no red meat. It is quite similar to the Mediterranean diet for fibromyalgia. The main difference is that the anti-inflammatory diet excludes dairy, while the Mediterranean diet allows it in moderation as long as it is low-fat.
Plant-Based Diet
A plant based diet may also be helpful for reducing fibromyalgia symptoms. This is because many plant based foods contain antioxidants, which help the body dispose of “free radicals.” These are waste products that the body produces naturally. High levels of free radicals in the body can lead to oxidative stress and inflammation.
Weight Management
Many people with fibromyalgia also have obesity. Excess weight may increase the risk of inflammation and oxidative stress. If fibromyalgia does involve inflammation, adopting a diet that encourages a person to reach or maintain a healthy weight may help.
Foods to Include
The following guidelines can help a person make anti-inflammatory diet choices.
- Eat eight to nine servings of fruits and vegetables per day: Eating a variety of colorful fruits and vegetables can ensure the greatest range of nutrients. Foods that are particularly rich in nutrients include broccoli and berries.
- Choose whole grains: Whole-grain foods include barley, buckwheat, oats, quinoa, brown rice, rye, wheat, and spelt. These foods provide vitamins, protein, and fiber.
- Choose healthful oils: Olive oil is a good choice.
- Incorporate herbs and spices: Many herbs and spices contain antioxidants, which may help reduce inflammation. Turmeric, bay leaves, cinnamon, and many others can offer benefits.
- Vitamin D: egg yolks, low fat yogurt fortified with vitamin D, orange juice fortified with vitamin D, swordfish and salmon, tuna, canned in water, whole-grain cereals fortified with vitamin D.
Foods and Additives to Avoid
A number of additives and ingredients may worsen the symptoms of fibromyalgia.
- Meat and dairy products: For people with fibromyalgia, it may help to limit excess dairy intake. This is because many dairy products contain saturated fat. People should try to opt for low fat versions or dairy alternatives such as soy milk. It may also help to limit the consumption of red meat. Instead of eating red meat every day, opt for turkey, fish, and vegetable based substitutes.
- Additives: According to the Arthritis Foundation, food additives called excitotoxins may worsen some of the symptoms of fibromyalgia. Examples of these include monosodium glutamate (MSG), which is a flavor enhancer, and aspartame, which is an artificial sweetener.
- Gluten: People with celiac disease must avoid gluten, or they may become very sick. However, recent research suggests that gluten might also affect the outlook for various inflammatory conditions.
- Other ingredients: saturated fats and trans fats, refined starches, foods with added sugar.
It may help to keep a food journal and record any symptoms that occur after eating particular food items. If any patterns emerge, it may be worth considering avoiding those foods for a while to see how this affects symptoms.
Additional Strategies for Managing Fibromyalgia
In addition to dietary changes, other strategies can help manage fibromyalgia symptoms.
Exercise
According to the American Academy of Family Physicians, engaging in aerobic exercise for 20-30 minutes per day on 2-3 days per week may help reduce symptoms and fatigue in people with fibromyalgia. Other physical activities that may help include: tai chi, weightlifting, yoga.
Sleep Hygiene
Getting regular, quality sleep can also help people manage the symptoms of fibromyalgia, waking up and going to sleep at the same time each day, building a relaxing activity into the bedtime routine, such as reading a book, listening to music, or meditating, maintaining a cool, dark, and comfortable sleep environment, leaving cell phones and other devices outside the bedroom.
Alternative Therapies
Other stress relieving activities that may help relieve fibromyalgia symptoms include: acupuncture, massage therapy, meditation, relaxation training, balneotherapy, homeopathy, magnetic therapies, reiki, counseling or therapy.
tags: #mediterranean #diet #fibromyalgia #benefits