Elevated levels of substance P (common to FMS) induces the release of pro-inflammatory cytokines IL‐8 (promotes sympathetic pain expression) and IL‐6, known to induce hyperalgesia, fatigue and depression. In addition, pro-inflammatory cytokines can act to steal tryptophan away from serotonin and melatonin pathways (via up-regulation of the enzymes IDO and TDO), increasing the activity of the NMDA agonist quinolinic acid, and further antagonising stimulation of NMDA pathways, which subsequently exacerbates mood and sleep issues. It has been observed that a number of cytokines may in fact play a direct role in FMS symptoms. [6] Magnetic resonance imaging (MRI) scans of the brains of FMS patients have shown significant shrinkage in the hippocampus; this is considered to be due to an imbalance between glutamate and gamma-aminobutyric acid (GABA) neurotransmission, together with dysregulation of glucocorticoids as a result of exposure to prolonged or traumatic stress. The shrinkage in hippocampal volume is directly linked to memory and cognitive issues experienced by FMS patients. [7]  

Increased levels of inflammatory cytokines can deplete levels of the key detoxification enzyme glutathione. The subsequent increase in oxidative stress can activate transcription factors, such as NF-κB, leading to further cytokine production. This increase in cytokine production further increases oxidative stress which in turn affects mitochondrial functioning and disrupts the production of ATP. This ATP deficit, together with inflammation and high oxidative stress, is believed to be responsible for the hallmark symptoms of ME/CFS/FMS, including post-exertion malaise. [8,9] The correlation between oxidative stress and FMS suggests that antioxidant requirements may be higher in sufferers, and while dietary manipulation can increase levels, supplementation might be more effective in achieving the levels needed to support its management.

Antioxidants that can be of benefit to FMS include: 

• Polyphenols & flavonoids such as curcumin & EGCG (found in green tea) and anthocyanins (found predominantly in teas, honey, wine, fruit, vegetables, nuts, olive oil & cocoa) up-regulate glutathione-related enzymes including glutathione reductase (GR) and glutathione S-transferase (GST)
• Cruciferous vegetables such as broccoli, kale and cabbage contain antioxidants that increase the production of detoxifying enzymes in the body 
• Sulphur-rich foods such as onions and garlic, cauliflower, eggs, Brussels sprouts & broccoli 
• Cysteine-rich foods such as soya beans, egg white, oats & tofu, provide the body with the nutrients that make up glutathione (L-cysteine + L-glutamic acid +glycine) 

Gut issues such as IBS are common in FMS and can affect as many as 70% of cases. In addition, hypochlorhydria (the absence or low production of stomach acid) is present in as many as half of all FMS patients. [10] Interestingly, an abnormal lactulose breath test as an indication of small intestinal bacterial overgrowth (SIBO) is more common in fibromyalgia than IBS. [11] SIBO is often associated with an increased intestinal permeability and this, combined with hypochlorhydria, can exacerbate gut inflammation, leading to compromised enterocyte function, low digestive enzyme production and, because the luminal content is able to interact with immune cells, will fuel systemic inflammation. Thus nutritional support aimed at optimising gut health should be a priority.

Nutrients known to support gut heath, mucus production, support tight junctions and secretory immunoglobulin type A (SIgA) levels include:  

• L-glutamine – fuels gut cells and boosts immunity
• Coconut oil/MCTs –antibacterial/antifungal 
• Bone broth / gelatine / collagen
• Vitamins D3 and A – increase SigA
• Aloe vera/liquorice/quercetin
• Digestive enzymes
• Apple cider vinegar / betaine HCl supplements/high dose ascorbic acid – increase natural stomach acid
• N-acetyl glucosamine – anti-inflammatory, helps protect the lining of the stomach and intestines
• FMS may present with protein malabsorption issues
• FMS patients appear to have low BCAA (leucine, isoleucine, and valine)

The diet recommended to those with fibromyalgia should consist of simple, healthy and unadulterated foods, with ‘junk’ foods and foods that are processed and highly refined being completely eliminated, as they are commonly linked to the triggering of symptoms. It is also important to eat small portions at regular intervals to ensure that the body’s nutritional requirements are continuously met, without overstressing digestive capacity at any point. Choosing organic fruit and vegetable produce, where possible, will also help to ensure that contaminants such as pesticides, herbicides and fertilisers are avoided, as these can contribute to chemical sensitivity, over-stress detoxification pathways and lead to exacerbation of pain. Organic produce is also much higher in vitamins and minerals, lower in omega-6, higher in omega-3 and, importantly, is free of the steroids and hormones associated with intense farming methods; all these improvements further support healthy biochemistry, reduce inflammation and support the body’s natural ability to heal.

As well as eating well at regular intervals, patients should try to avoid/minimise stress and aim for 7-8 hours of good quality, restorative sleep as further, important aids in managing symptoms.  

CoQ10, as ubiquinol, plays a vital role in both ATP production and as a free radical scavenger. In a 2013 study, ubiquinol supplementation (100 mg/day for 12 weeks) not only resulted in an increase in coenzyme Q10 levels but also improved chronic fatigue scores as measured by the Chalder Fatigue Scale. [13] Use of ubiquinol supplements may be a useful intervention for FMS, especially given that meta-analysis of CoQ10 supplementation studies also support its use to improve the process of inflammatory state by lowering proinflammatory cytokines. [14,15]

FMS is clearly a highly complex syndrome in which the interaction of chemicals, hormones and proteins, both alone and in combination, give rise to a multitude of symptoms. Pain is the predominant, but not exclusive, symptom and can be triggered by a number of factors including nutrient deficiencies, high oxidative stress and unresolved inflammation, all of which are targets for nutritional support. Accumulating evidence supports the role of dietary changes in combination with targeted nutrient interventions, for successful improvement of symptom severity.

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