by Holistic Osteopath, Marcus Webb
By the time you read this little article I am sure you will have heard about a study linking gluten sensitivity with fibromyalgia and reporting on how ‘remarkable clinical improvement can be achieved with a gluten-free diet in patients with fibromyalgia (FM) even if coeliac disease has been ruled out’. The conclusion also goes on to say that ‘non-coeliac gluten sensitivity may be an underlying treatable cause in FM syndrome’.
However, the plot thickens; in all 20 of the FM subjects studied biopsies of their intestine revealed a pathological change known as intraepithelial lymphocytosis, a finding the authors use to help support their hypothesis that gluten sensitivity is a causal agent and underlies FM. This cause and effect relationship that this latest study hints at does sound convincing especially when we keep in mind that intraepithelial lymphocytosis has been associated with gluten sensitivity in the past but should we be jumping to such a definitive conclusion; what about those FM patients who don’t have intraepithelial lymphocytosis, were they removed from the study because they did not respond to a gluten-free diet? Don’t get me wrong, I am not trying to discredit or down play the study or the potential benefits of a gluten free diet in cases of FM but I am aware that many FM sufferers may read this and feel that they have to follow a gluten-free diet in order to get better but before going on it may be good to lay out a little additional information about intraepithelial lymphocytosis.
Within the tissue of the gut known as (epithelial tissue) special white blood cells known as lymphocytes reside waiting like guard on duty to be triggered into life by an invading army. In the case of the gut this is would normally be a bacterial infection. In around 3% of routine biopsies increased levels of lymphocytes can be observed (ie. intraepithelial lymphocytosis) and between 9-40% of cases celiac disease has eventually been diagnosed. In some cases intraepithelial lymphocytosis occurs in other multi-system disorders such as Hashimoto’s thyroiditis, Graves’s disease, rheumatoid arthritis, psoriasis, multiple sclerosis, Systemic lupus erythematosus, ankylosing spondylitis and autoimmune enteropathy. The other cases tend to be viewed as a non-specific finding related to other health issues such as bacterial overgrowth (SEBO), inflammatory damage secondary to non-steroidal anti-inflammatory drug use or other chronic inflammatory bowel disease. In other words, the presence of intraepithelial lymphocytosis is not diagnostic of gluten sensitivity but in the absence of other causes gluten sensitivity could be a possibility since it has been reported to account for around 10% of the cases of intraepithelial lymphocytosis but it should be kept in mind that hypersensitivity to other non-gluten components of food may also trigger this tissue change. Interestingly, a good number of the 20 subjects had co-existing health problems that have also been linked with the bowel tissue chances characteristic of intraepithelial lymphocytosis such as psoriasis (in 2 cases), hypothyroidism (in 3 cases), inflammarory/irritable bowel (in 5 cases) and gastric reflux (in 10 cases) which is a problem that commonly receives PPI drug therapy. As a drug class, PPI’s are also known to trigger intraepithelial lymphocytosis. However you critique this study as much as you want but what you can’t ignore is the outcome; for many, great relief of their chronic and disabling symptoms using a drug-free approach.
For many FM sufferers having a condition that is resistant to conventional therapies places them in a real corner when it comes to treatment and management options. From my experiences working with FM/CFS sufferers we tend to do what works or what works for that person! Science tends to take its time in catching up with the clinical observations but while it is catching up in many cases there is no real harm in exploring options that appear to have some evidence to support their use such as a trial of a gluten-free diet. From the results of the current study the gluten-free diet was followed for 16 months on average but in one case (a FM sufferer for 20 years) improvement in pain, fatigue and gut symptoms were felt after just 5 months and in another case (a sufferer for 10 years) complete remission of FM and improvements in gut and migraine was also observed after just 5 months. In some cases significant improvements and a return to normal life activities and work were seen after more prolonged (over 30 months) exposure to the gluten-free diet. However you look at it, cutting the gluten has made a dramatic difference to many sufferers in this small study.
If you feel that a gluten free approach is something you fancy trying its not a diet to be taken on lightly… so many foods contain gluten! Despite this, I would advise that you seriously consider going gluten free if your FM is of long standing and you have exhausted all other approaches. Keep in mind that you may have to stick to it for many months before you feel any tangible benefits but again, for what its worth, I can support the observations that many ill-defined inflammatory and pain related conditions simply improve with the elimination of gluten.
To help get you started you should avoid Barley, bulgar wheat, couscous, durum wheat, rye, semolina, spelt, wheat, all biscuits, breads, cakes, chapattis, crackers, muffins, pastries, pizza bases, muesli, wheat based breakfast cereals and anything made from wheat, rye or barley flour. By no stretch of the imagination is this a complete gluten free diet but it’s a start and something you can instigate today. Sitting down with an experienced nutritionist or naturopath should be your next step so you can get a more complete understanding of the complete gluten free diet and what it involves. In the early days of a gluten free diet I tend to recommend the use of a special dietary enzyme supplement based in a blend of plant derived gluten splitting enzymes. In addition to the cellulose digesting enzyme known as cellulase the key ingredient in Gluten Relief is Dipeptidyl Peptidase IV (or DPP-IV for short). DPP-IV is a type of protein splitting enzyme, known as a protease, and has been shown to break down the wheat protein gluten and milk protein casein. This combines with alpha-galactosidase to aid in the digestion of long chain sugars found in beans, broccoli, cabbage, sprouts etc… Using an enzyme preparation such as Gluten Relief (by the Canadian manufacturer Natural Factors) does not replace in anyway a gluten free diet but when you are unsure or are out and about with limited choices it may help to ‘defuse’ a potential gluten containing meal.
Link to study: Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia.
Link to Gluten Relief product