When I was in my early 20’s I was diagnosed with Celiac Disease (CD). After eating a meal containing anything with gluten, my belly would bloat, and I would feel extremely fatigued. I was a vegetarian at the time and was consuming a lot of grains, including wheat. Let’s just say I made good use of the perks at my Subway job. The blood tests for gluten-specific antibodies and an endoscopy merely confirmed what I already suspected.
In truth, the celiac diagnosis wasn’t a huge surprise; CD is a genetic condition, and I have an (unfortunate) family history. In addition, I picked up a bug while traveling, and the resulting illness might have been the final straw.
After the celiac diagnosis, I made significant dietary changes and began the process of letting my body heal from the inflammation that had been caused by consuming gluten. I was feeling better and was certain I was on the right track, in spite of intermittent GI issues that were attributed to Irritable Bowel Syndrome (IBS).
Fast forward 5 years, and I began developing symptoms consistent with fibromyalgia (FM) such as fatigue, “brain fog”, sore joints, and tingling in my arms and legs. My FM diagnosis was not as quick in coming. However after two years, much self-advocacy, and numerous visits to specialists (some of whom had a very cursory knowledge of FM), I was formally diagnosed.
It was all unbelievable to me. In the space of 5 years, I had been tagged with three diagnoses': celiac (an auto-immune disease), FM (a central nervous system disorder) and IBS which is thought to be caused by multiple bacterial overgrowth, psychological factors, and central nervous system dysregulation. Was I just really unlucky, or was there a correlation?
I began to do some research and learned that the intersection (co-morbidity) of CD, FM, and IBS is quite common. I also came upon a growing body of research that suggests gluten exacerbates the symptoms of fibromyalgia (FM), even for individuals who do not meet the diagnostic criteria for celiac disease (CD).
Let’s take a deeper dive and examine the implications of this unholy trinity.
What is Gluten and Gluten Sensitivity?
Gluten is a protein that is found in certain grains including wheat, rye, barley, spelt, and triticale. Anyone with CD knows which grains to avoid. Unfortunately, while wheat bread or barley soup are an obvious source of gluten, it can sneak into our food in unexpected ways. For example, soy sauce is often brewed using wheat and can be added to a dish as a flavouring.
I’ve been caught off guard on more than one occasion when a meal that I was assured was gluten-free ended up giving me a severe inflammatory response. Learning about the possible ways you can inadvertently ingest gluten is an absolute necessity, and I’ve learned to ask the right questions when I’m eating a meal that I haven’t prepared myself.
Think of gluten sensitivity as a spectrum. On one end is celiac disease (CD). For some individuals, even a minuscule amount of gluten (such as cross contamination from a jar of mayonnaise), can lead to an extreme inflammatory response. Confoundingly, other celiacs can consume some gluten and remain asymptomatic.
For context, a product must contain less than 20 ppm of gluten per million to be labeled gluten free. Imagine 20 red balls in a bin of a million black balls – it's not a lot.
On the other end of the spectrum is non-celiac gluten sensitivity (NCGS), a relatively new diagnosis that may affect up to 13% of the general population. (1) People with NCGS may exhibit some of the same symptoms as CD, albeit on a lesser scale, or have no discernible reaction but just sense that they’re not operating at peak efficiency. Also included in the spectrum is wheat allergy, a relatively rare reaction to other proteins found in wheat.
As I mentioned, research has found a higher prevalence of celiac disease and NCGS among individuals with chronic illnesses, including fibromyalgia. (2) In addition, patients with IBS are also affected by numerous co-morbidities, notably fibromyalgia. Some studies have even suggested that the body’s inflammatory response to gluten may trigger the onset of FM. (3)
It’s estimated that 20% to 32% of individuals with IBS meet the diagnostic criteria for FM. Likewise, 32% to 70% of individuals with FM also meet the criteria for IBS. In many cases, IBS is a common denominator for an individual who has fibromyalgia and CD or NCGS. (4)
Why Is There Such a Strong Connection?
While more research is needed to definitively determine the reasons for the overlap, some robust theories have been advanced. They include potential shared genetic predispositions, common inflammatory and pain pathways, food allergies (in addition to gluten), changes in gut microbiota, and environmental causes. These factors, either alone or in concert, are thought to contribute to the strong correlation that has been identified by researchers.
Immune System and Inflammation
One of the primary pathways linking FM, CD and IBS is chronic inflammation and immune dysregulation. In CD, the ingestion of gluten triggers an autoimmune response, leading to inflammation and damage to the small intestine. This chronic inflammation may have systemic spillover, thus contributing to and/or compounding the symptoms seen in other conditions, much like adding layers to a birthday cake.
Although NCGS does not involve the autoimmune response and markers seen in celiac disease, it also creates inflammatory reactions that can lead to similar gastrointestinal symptoms and systemic inflammation. Because FM is characterized by abnormal immune responses and widespread inflammation, there is mounting evidence that it is worsened by chronic conditions such as CD and NCGS. (5)
Finally, IBS is characterized by chronic, low-grade inflammation. This inflammation can also alter gut health and sensitivity, contributing to the typical IBS symptoms, and once again amplifying the experience of the other conditions.
Gastrointestinal Symptoms and the Gut-Brain Axis
Gastrointestinal symptoms are a common thread in celiac disease, NCGS, IBS, and FM, suggesting a significant role of the gut-brain axis. This bidirectional communication between the gastrointestinal tract and the brain via the vagus nerve is crucial in understanding the overlap. Dysregulation of this pathway can lead to both gastrointestinal symptoms (as seen in IBS and celiac disease) and systemic symptoms such as chronic pain and fatigue (common in FM). (6)
Furthermore, disruption of the gut microbiota (called dysbiosis) is common in these conditions. In celiac disease and IBS, dysbiosis can increase intestinal permeability (leaky gut), allowing larger molecules to enter the bloodstream, further exacerbating FM symptoms.
Dietary Factors and FODMAPs
Dietary management, particularly the role of gluten and FODMAPs, is critical in these overlapping conditions. Obviously, a gluten-free diet is a necessity when addressing CD and NCGS. But it can also alleviate symptoms in some individuals who have IBS. (7)
Many gluten-containing foods are also high in FODMAPs, an acronym for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols. Don’t let the organic chemistry terminology throw you off. Put more simply, FODMAPs are certain types of carbohydrates, which are the sugars, starches, and fiber in foods.
A temporary and highly restrictive low FODMAP diet is often initiated as a first step for many IBS patients, highlighting the role of fermentable carbohydrates in gastrointestinal distress.
Neurological and Psychological Factors
Neurological and psychological factors can further contribute to the overlap among these conditions. In FM, central sensitization, where the central nervous system becomes sensitized to pain signals, can be worsened by gastrointestinal issues. This heightened pain perception is thought to overlap with the abdominal pain that characterizes IBS and CD.
Likewise, psychological stress, which as we know can trigger an FM flare, also affects the severity of IBS symptoms. (8)
Environmental Impacts
In a study published in 2014 by Samsel and Seneff in “Interdisciplinary Toxicology” they reviewed levels of gluten intolerance across generations and found that celiac and gluten sensitivity has increased by approximately four times since the 1950’s, even when allowing for better diagnostic tools. The culprit? The use of glyphosate, the ingredient in the herbicide Roundup. (9)
Numerous other studies have concluded that glyphosate and other herbicides and chemicals in our environment can cause gut bacteria overgrowth, a contributing factor to IBS, and negatively impact the central nervous system and inflammatory responses, directly contributing to the rise of chronic illnesses. (10)
Genetic Predisposition
Genetic factors may also play a role in the co-morbidity of these conditions. Genetic markers such as HLA-DQ2 and HLA-DQ8, which increase the risk of CD, may also predispose individuals to FM and IBS due to their role in immune responses. (11)
Summary:
As we just learned, research is beginning to bring the IBS, FM, and gluten connection into much clearer focus. While there’s nothing we can do about the genetic factor (other than to curse our ancestors), some of the other suspected root causes can be addressed. I want to stress that before you undertake any of these potential courses of action, you should first consult your healthcare provider and/or a dietitian.
Things to Discuss With Your Health Care Providers
Diet
Eliminating gluten entirely from your diet is an obvious first step. However, given the prevalence of the co-morbidities we’ve been discussing, if you’ve been diagnosed with FM you should ask (insist) on having tests and clinical assessments done for IBS, CD and NCGS.
One of the major problems with the IBS, gluten sensitivity, and FM axis is that the conditions share many common symptoms, making both the diagnosis and treatment of your symptoms harder. Knowing exactly what you’re dealing with will be helpful in determining next steps.
Next, it is often helpful to get bloodwork done to assess any nutritional deficiencies. A prevalent side effect of CD and NCGS is that the intestines become so inflamed and damaged that they can't properly absorb nutrients from your food. Malabsorption of micronutrients such as iron, zinc, magnesium, copper, folate, vitamin B 12 and vitamin D are common. If the identified deficiencies persist, your healthcare providers may prescribe supplements.
Another possibility is that foods other than the gluten-containing ones we discussed may be causing an allergic reaction and causing what is known as Small Intestine Bacterial Overgrowth (SIBO). SIBO is a well-established factor aggravating IBS symptoms. I’ve attached a guide to the FODMAP diet to give you the basics at this link.
The FODMAP diet is a strict diet that temporarily eliminates most of the known allergy-inducing foods. After a reset period, you’ll begin to reintroduce them in a controlled fashion while carefully monitoring your body’s reaction. Unfortunately, you’re probably going to miss a lot of the things you’ll be eliminating (ice cream, for example). Over time some or even all of the FODMAPS may be safely reintroduced, but perhaps at lower levels of consumption. Again, I can’t stress enough the need to be under the supervision of a healthcare professional if you proceed down this path.
Finally, since we're on the topic of diet, one of the worst foods that we habitually consume is sugar. It’s highly inflammatory, and no one really needs calories devoid of nutritional benefits. Beyond a doubt reducing sugar intake can yield huge benefits in your overall health, and your susceptibility to disease and fibro flares.
Unfortunately, artificial sweeteners, such as aspartame, saccharin and sucralose come with their own negative impacts. We will examine sugar and sugar substitutes, and their effect on FM, in a later post.
Gut Health
It’s estimated your gut is occupied by 30 to 400 trillion organisms including bacteria, fungi, protozoa and viruses. This community of microscopic inhabitants called the gut microbiome, is essential for digestive health, pathogen protection, the immune system, and even mental health.
Finding the right balance between the various strains of critters is essential, especially since they are often adversely impacted by IBS and CD. A naturopath or GI doctor will be able to advise you on how to bring them to an optimal balance and may suggest such things as changes to your diet and lifestyle and the use of probiotics.
Stress and Sleep
While none of us can be guaranteed a stress-free life, too much stress causes illness. Personally, when I’m under a lot of stress I know I have to decompress or face the consequences in the form of an FM flare. As previously noted, stress can also trigger the symptoms of IBS. Therapy, meditation, exercise (just don’t overdo it), and yoga are common non-medicinal courses of action. If you’d like to learn more about an effective stress-reduction technique called EFT (Tapping), check out my blog post here.
Conclusion
The connection between Celiac Disease and Non-Celiac Gluten Sensitivity, Irritable Bowel Syndrome, and Fibromyalgia, while firmly established by research, is complex, and not fully understood. People with FM are affected by gluten sensitivities and IBS at a much higher rate than the general population. Getting a proper diagnosis for each condition is an important first step toward understanding your options and reducing the worst of your symptoms.
By treating each condition properly and taking the prescribed courses of action, it is possible to greatly reduce the physical, neurological, and emotional toll that comes from having two or more of these common co-morbidities.
You can read more about my personal journey (and others’) with getting diagnosed and living with Celiac Disease here. Beyond Celiac also offers a wealth of great resources for those with CD and NCGS.
Citations:
Barbaro MR, Cremon C, Stanghellini V, Barbara G. Recent advances in understanding non-celiac gluten sensitivity. F1000Res. 2018 Oct 11;7:F1000 Faculty Rev-1631. doi: 10.12688/f1000research.15849.1. PMID: 30363819; PMCID: PMC6182669
Rodrigo L, Blanco I, Bobes J, de Serres FJ. Remarkable prevalence of coeliac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study. Arthritis Res Ther. 2013;15(6):R201. doi: 10.1186/ar4391. PMID: 24283458; PMCID: PMC3978893.
Isasi C, Colmenero I, Casco F, Tejerina E, Fernandez N, Serrano-Vela JI, Castro MJ, Villa LF. Fibromyalgia and non-celiac gluten sensitivity: a description with remission of fibromyalgia. Rheumatol Int. 2014 Nov;34(11):1607-12. doi: 10.1007/s00296-014-2990-6. Epub 2014 Apr 12. PMID: 24728027; PMCID: PMC4209093.
Is There a Link Between IBS, Fibromyalgia, and Celiac Disease? Medical Professionals Reference - Article by Batya Swift Yasgur, MA, LSW | December 26, 2013 (includes external citations)
Valencia C, Fatima H, Nwankwo I, et al. (October 04, 2022) A Correlation Between the Pathogenic Processes of Fibromyalgia and Irritable Bowel Syndrome in the Middle-Aged Population: A Systematic Review. Cureus 14(10): e29923. doi:10.7759/cureus.29923
Erdrich S, Hawrelak JA, Myers SP, Harnett JE. Determining the association between fibromyalgia, the gut microbiome and its biomarkers: A systematic review. BMC Musculoskelet Disord. 2020 Mar 20;21(1):181. doi: 10.1186/s12891-020-03201-9. PMID: 32192466; PMCID: PMC7083062.
Pinto-Sanchez MI, Nardelli A, Borojevic R, De Palma G, Calo NC, McCarville J, Caminero A, Basra D, Mordhorst A, Ignatova E, Hansen S, Uhde M, Norman GL, Murray JA, Smecuol E, Armstrong D, Bai JC, Schuppan D, Collins SM, Alaedini A, Moayyedi P, Verdu EF, Bercik P. Gluten-Free Diet Reduces Symptoms, Particularly Diarrhea, in Patients With Irritable Bowel Syndrome and Antigliadin IgG. Clin Gastroenterol Hepatol. 2021 Nov;19(11):2343-2352.e8. doi: 10.1016/j.cgh.2020.08.040. Epub 2020 Aug 19. PMID: 32827724.
Staudacher HM, Black CJ, Teasdale SB, Mikocka-Walus A, Keefer L. Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management. Nat Rev Gastroenterol Hepatol. 2023 Sep;20(9):582-596. doi: 10.1038/s41575-023-00794-z. Epub 2023 Jun 2. PMID: 37268741; PMCID: PMC10237074.
Samsel A, Seneff S. Glyphosate, pathways to modern diseases II: Celiac sprue and gluten intolerance. Interdiscip Toxicol. 2013 Dec;6(4):159-84. doi: 10.2478/intox-2013-0026. PMID: 24678255; PMCID: PMC3945755.
Environmental Determinants of Chronic Disease and Medical Approaches: Recognition, Avoidance, Supportive Therapy, and Detoxification. Margaret E. Sears, Stephen J. Genuis First published: 19 January 2012 https://doi.org/10.1155/2012/356798
Aboulaghras, Sara, Daniela Piancatelli, Khalid Taghzouti, Abdelaali Balahbib, Mohammed Merae Alshahrani, Ahmed Abdullah Al Awadh, Khang Wen Goh, Long Chiau Ming, Abdelhakim Bouyahya, and Khadija Oumhani. 2023. "Meta-Analysis and Systematic Review of HLA DQ2/DQ8 in Adults with Celiac Disease" International Journal of Molecular Sciences 24, no. 2: 1188. https://doi.org/10.3390/ijms24021188
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