Abstract
Background and aims
Fibromyalgia (FM) is a chronic, rheumatic disease characterized by widespread myofascial pain, of unknown aetiology, having a major impact on quality of life (QOL). Available pharmacotherapy for FM is marginally effective. FM is associated with co-morbidities of gastrointestinal (GI) disorders and Irritable Bowel Syndrome (IBS). There is growing evidence that diets low in FODMAPs, “fermentable oligo-, di- or mono-saccharides and polyols” [Low FODMAP Diet (LFD)], are effective in treating IBS. The aim of this pilot study was to examine the effects of LFDs on symptoms of FM, especially with regard to pain, QOL and GI disorders.
Methods
A longitudinal study using LFD intervention was performed on 38, 51±10 year-old, female patients diagnosed with FM for an average of 10 years, based on ACR (American College of Rheumatology) 2010 criteria. The study was conducted from January through May, 2015, using a four-week, repeated-assessment model, as follows: Moment 0 – introduction of the protocol to participants; Moment 1 – first assessment and delivery of individual LFD dietary plans; Moment 2 – second assessment and reintroduction of FODMAPs; Moment 3 – last assessment and final nutritional counselling. Assessment tools used were the following: RFIQ (Revised Fibromyalgia Impact Questionnaire), FSQ (Fibromyalgia Survey Questionnaire), IBS-SSS (Severity Score System), EQ-5D (Euro-QOL quality of life instrument), and VAS (Visual Analogue Scale). Daily consumption of FODMAPs was quantified based on published food content analyses. Statistical analyses included ANOVA, non-parametric Friedman, t-student and Chi-square tests, using SPSS 22 software.
Results
The mean scores of the 38 participants at the beginning of the study were: FSQ (severity of FM, 0–31) – 22±4.4; RFIQ (0–100) – 65±17; IBS-SSS (0–500) – 275± 101; and EQ-5D (0–100) – 48± 19. Mean adherence to dietary regimens was 86%, confirmed by significant difference in FODMAP intakes (25 g/day vs. 2.5 g/day; p < 0.01). Comparisons between the three moments of assessment showed significant (p < 0.01) declines in scores in VAS, FSQ, and RFIQ scores, in all domains measured. An important improvement was observed with a reduction in the severity of GI symptoms, with 50% reduction in IBS scores to 138±117, following LFD therapy. A significant correlation (r = 0.36; p < 0.05) was found between improvements in FM impact (declined scores) and gastrointestinal scores. There was also a significant correlation (r = 0.65; p < 0.01) between “satisfaction with improvement” after introduction of LFDs and “diet adherence”, with satisfaction of the diet achieving 77% among participants. A significant difference was observed between patients who improved as compared to those that did not improve (Chi-square χ2 = 6.16; p < .05), showing that the probability of improvement, depends on the severity of the RFIQ score.
Conclusions
Implementation of diet therapy involving FODMAP restrictions, in this cohort of FM patients, resulted in a significant reduction in GI disorders and FM symptoms, including pain scores. These results need to be extended in future larger studies on dietary therapy for treatment of FM.
Implications
According to current scientific knowledge, these are the first relevant results found in an intervention with LFD therapy in FM and must be reproduced looking for a future dietetic approach in FM.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.06.001.
Statement of authorship: Ana Paula Marum contributed to concept/design, data collection/analysis/interpretation, and drafting article; Cátia Moreira contributed to dietary plans and nutritional quantifications, Pablo Tomas-Carus contributed to recruitment, critical revision of article, Fernando Saraiva contributed to recruitment and critical revision of article, Catarina Sousa Guerreiro contributed to concept/design, revising it critically for important intellectual content and final approval of the version to be submitted.
Funding: Not applicable.
Ethical issues: All participants signed informed consent agreements according to the Helsinki Declaration of the AMM 2013 version. The project was approved by the Ethics Commission of the Medical Academic Centre of Lisbon.
Conflict of interest: Author Ana Paula Marum, Author Cátia Moreira, Author Fernando Saraiva, Author Pablo Tomas-Carus and Author Catarina Sousa Guerreiro, declare that they have no conflict of interest.
Acknowledgments
We thank to Santa Maria Hospital, Department of Rheumatology, and Myos Association the consent and logistic support for the field research. We also thank Prof. Elisabete Carolino and Prof. Alice Gonçalves for statistical assistance and Dr. Bruce Campbell for the English revision.
References
[1] Borchers AT, Gershwin ME. Fibromyalgia: a critical and comprehensive review. Clin Rev Allergy Immunol 2015;49:100–51, http://dx.doi.org/10.1007/s12016-015-8509-4.10.1007/s12016-015-8509-4Suche in Google Scholar PubMed
[2] Bellato E, Marini E, Castoldi F, Barbasetti N, Mattei L, Bonasia DE, Blonna D. Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat 2012;2012:426130, http://dx.doi.org/10.1155/2012/426130.10.1155/2012/426130Suche in Google Scholar PubMed PubMed Central
[3] Branco JC, Bannwarth B, Failde I, Abello Carbonell J, Blotman F, Spaeth M, Saraiva F, Nacci F, Thomas E, Caubère JP, Le Lay K, Taieb C, Matucci-Cerinic M. Prevalence of Fibromyalgia: a survey in five european countries. Semin Arthritis Rheum 2010;39:448–53, http://dx.doi.org/10.1016/j.semarthrit.2008.12.003.10.1016/j.semarthrit.2008.12.003Suche in Google Scholar PubMed
[4] Laroche F, Guérin J. Fibromyalgie: où en est-on en 2015? Douleur et Analgésie 2015;28:31–9, http://dx.doi.org/10.1007/s11724-015-0407-2.10.1007/s11724-015-0407-2Suche in Google Scholar
[5] Häuser W, Thieme K, Turk DC. Guidelines on the management of fibromyalgia syndrome – a systematic review. Eur J Pain 2010;14:5–10, http://dx.doi.org/10.1016/j.ejpain.2009.01.006.10.1016/j.ejpain.2009.01.006Suche in Google Scholar PubMed
[6] Ángel García D, Martínez Nicolás I, Saturno Hernández P. Clinical approach to fibromyalgia: synthesis of evidence-based recommendations, a systematic review. Reumatol Clín 2015;803:4–7, http://dx.doi.org/10.1016/j.reuma.2015.06.001.10.1016/j.reumae.2015.06.002Suche in Google Scholar
[7] Nishida C, Uauy R, Kumanyika S, Shetty P. The joint WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases: process, product and policy implications. Public Health Nutr 2004;7:245–50, http://dx.doi.org/10.1079/PHN2003592.10.1079/PHN2003592Suche in Google Scholar PubMed
[8] Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi LFM. Fibromyalgia and nutrition: what news? Clin Exp Rheumatol 2015;33:S117–25.Suche in Google Scholar
[9] Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr 2016, http://dx.doi.org/10.1007/s00394-015-0922-1.10.1007/s00394-015-0922-1Suche in Google Scholar PubMed
[10] Barrett JS, Gibson PR. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Therap Adv Gastroenterol 2012;5:261–8, http://dx.doi.org/10.1177/1756283X11436241.10.1177/1756283X11436241Suche in Google Scholar PubMed PubMed Central
[11] Helfenstein M, Heymann R, Feldman D. Prevalence of irritable bowel syndrome in patients with fibromyalgia. Rev Bras Reum 2006;46:16–23.Suche in Google Scholar
[12] Veale D, Kavanagh G, Fieldding JF, Fitzgerald O. Primary fibromyalgia and the irritable bowel syndrome: different expressions of a common pathogenetic process. Rheumatology 1991;30:220–2, http://dx.doi.org/10.1093/rheumatology/30.3.220.10.1093/rheumatology/30.3.220Suche in Google Scholar PubMed
[13] Holton KF, Kindler LL, Jones KD. Potential dietary links to central sensitization in fibromyalgia: past reports and future directions. Rheum Dis Clin North Am 2009;35:409–20, http://dx.doi.org/10.1016/j.rdc.2009.06.003.10.1016/j.rdc.2009.06.003Suche in Google Scholar PubMed
[14] Berstad A, Undseth R, Lind R, Valeur J. Functional bowel symptoms, fibromyalgia and fatigue: a food-induced triad? Scand J Gastroenterol 2012;47:914–9, http://dx.doi.org/10.3109/00365521.2012.690045.10.3109/00365521.2012.690045Suche in Google Scholar PubMed PubMed Central
[15] Arranz L-I, Canela M-Á, Rafecas M. Dietary aspects in fibromyalgia patients: results of a survey on food awareness, allergies, and nutritional supplementation. Rheumatol Int 2012;32:2615–21, http://dx.doi.org/10.1007/s00296-011-2010-z.10.1007/s00296-011-2010-zSuche in Google Scholar PubMed
[16] Slim M, Calandre EP, Rico-Villademoros F. An insight into the gastrointestinal component of fibromyalgia: clinical manifestations and potential underlying mechanisms. Rheumatol Int 2014;35:433–44, http://dx.doi.org/10.1007/s00296-014-3109-9.10.1007/s00296-014-3109-9Suche in Google Scholar PubMed
[17] Slim M, Molina-Barea R, Garcia-Leiva JM, Rodríguez-Lopez CM, Morillas-Arques P, Rico-Villademoros F, Calandre EP. The effects of gluten-free diet versus hypocaloric diet among patients with fibromyalgia experiencing gluten sensitivity symptoms: protocol for a pilot, open-label, randomized clinical trial. Contemp Clin Trials 2015;40:193–8, http://dx.doi.org/10.1016/j.cct.2014.11.019.10.1016/j.cct.2014.11.019Suche in Google Scholar PubMed
[18] Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology 2013;145:320–8, http://dx.doi.org/10.1053/j.gastro.2013.04.051.10.1053/j.gastro.2013.04.051Suche in Google Scholar PubMed
[19] De Giorgio R, Volta U, Gibson PR. Sensitivity to wheat, gluten and FODMAPs in IBS: facts or fiction? Gut BMJ 2015:1–10, http://dx.doi.org/10.1136/gutjnl-2015-309757.10.1136/gutjnl-2015-309757Suche in Google Scholar PubMed
[20] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol 2011;38:1113–22, http://dx.doi.org/10.3899/jrheum.100594.10.3899/jrheum.100594Suche in Google Scholar PubMed
[21] Bennett RM, Friend R. The Revised Fibromyalgia Impact Questionnaire(FIQR): validation and psychometric proporties. Arthr Res Ther 2009;11:R120, http://dx.doi.org/10.1186/ar2783.10.1186/ar2783Suche in Google Scholar PubMed PubMed Central
[22] Salgueiro M, García-Leiva JM, Ballesteros J, Hidalgo J, Molina R, Calandre EP. Validation of a Spanish version of the Revised Fibromyalgia Impact Questionnaire (FIQR). Health Qual Life Outcomes 2013;11:132, http://dx.doi.org/10.1186/1477-7525-11-132.10.1186/1477-7525-11-132Suche in Google Scholar PubMed PubMed Central
[23] Almansa C, Sánchez RG, Barceló M, Díaz-rubio M, Rey E. Traducción, adaptación cultural y validación al españ ol del cuestionario de gravedad del síndrome de intestino irritable (Irritable Bowel Syndrome Severity Score). Rev Esp Enfermedades Dig 2011;103:612–8.10.4321/S1130-01082011001200002Suche in Google Scholar
[24] Ferreira PL, Ferreira LN, Pereira LN. Contributos para a validaç ão da versão portuguesa do EQ-5D. Acta Med Port 2013;26:664–75.10.20344/amp.1317Suche in Google Scholar
[25] Biesiekierski JR, Rosella O, Rose R, Liels K, Barrett JS, Shepherd SJ, Gibson PR, Muir JG. Quantification of fructans, galacto-oligosacharides and other short-chain carbohydrates in processed grains and cereals. J Hum Nutr Diet 2011;24:154–76, http://dx.doi.org/10.1111/j.1365-277X.2010.01139.x.10.1111/j.1365-277X.2010.01139.xSuche in Google Scholar PubMed
[26] Muir JG, Rose R, Rosella O, Liels K, Barrett JS, Shepherd SJ, Gigson PR. Measurement of short-chain carbohydrates in common Australian vegetables and fruits by high-performance liquid chromatography (HPLC). J Agric Food Chem 2009;57:554–65, http://dx.doi.org/10.1021/jf802700.10.1021/jf802700eSuche in Google Scholar PubMed
[27] Rao SSC, Yu S, Fedewa A. Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome. Aliment Pharmacol Ther 2015;41:1256–70, http://dx.doi.org/10.1111/apt.13167.10.1111/apt.13167Suche in Google Scholar PubMed
[28] Staudacher HM, Lomer MCE, Anderson JL, Barrett JS, Muir JG, Irving PM, Whelan K. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr 2012;142:1510–8, http://dx.doi.org/10.3945/jn.112.159285.10.3945/jn.112.159285Suche in Google Scholar PubMed
[29] Forsythe P, Sudo N, Dinan T, Taylor VH, Bienenstock J. Mood and gut feelings. Brain Behav Immun 2010;24:9–16, http://dx.doi.org/10.1016/j.bbi.2009.05.058.10.1016/j.bbi.2009.05.058Suche in Google Scholar PubMed
[30] Pérez y López N, Torres-López E, Zamarripa-Dorsey F. Respuesta clínica en pacientes mexicanos con síndrome de intestino irritable tratados con dieta baja en carbohidratos fermentables (FODMAP). Rev Gastroenterol México 2015;80:180–5, http://dx.doi.org/10.1016/j.rgmx.2015.06.008.10.1016/j.rgmx.2015.06.008Suche in Google Scholar PubMed
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