Key Practice Point #1
Recommendation
There is insufficient evidence to support the effectiveness of any diet or nutritional supplement for managing symptoms of ME/CFS.
The 2021 NICE guidelines include general dietary guidance based on managing complications of ME/CFS related to nausea; dysphagia; and difficulties buying, preparing and eating food; and referring individuals to a dietitian who present with malnutrition or a restrictive diet.
A 2017 consensus document for management of ME/CFS in young individuals suggests eliminating caffeine beverages in the late afternoon and evening as caffeine can cause tachycardia and agitation and exacerbate sleep problems. Additional suggestions include consuming regular, small meals and snacks and avoiding large amounts of fluids with meals to address symptoms of anorexia, nausea and bloating.
Evidence Summary
A 2017 systematic review and 2021 follow-up review by the same investigative group examining dietary and nutritional interventions for treating ME/CFS identified 14 interventions described in generally single, small, short-term studies of heterogeneous design. Although some studies reported modest improvements in some ME/CFS symptoms with nutrition supplements (i.e. NADH, ubiquinol-10, polyphenol, probiotics, pollen extract), the authors concluded that study limitations provided insufficient evidence for using nutritional supplements or modified diets to improve symptoms of ME/CFS.
Grade of Evidence D
Remarks
ME/CFS has also been defined as systemic exertion intolerance disease. Symptoms include debilitating fatigue, post-exertion malaise and unrefreshing sleep, combined with orthostatic intolerance or cognitive decline that lasts for six months or more. The etiology of ME/CFS is unknown but has been attributed to infectious illness, stress and environmental toxins. The characteristics of long COVID suggest an overlap of many symptoms with ME/CFS.
Evidence
- A systematic review (searched to 2016) examined evidence for nutritional interventions for treating symptoms of ME/CFS (1). The review followed PRIMSA standards and identified 17 studies including six RCTs, three crossover RCTs, three uncontrolled studies, one cohort study and four pilot studies. A total of 14 different interventions were included of predominantly nutritional supplements (multivitamins, vitamin D, ubiquinol, acetyl carnitine, coenzyme Q10, NADH, guanidinoacetic acid, polyphenol, probiotics, pollen extract or "multinutritional" supplement) and one dietary study comprised a low sugar, low yeast diet. The majority of studies diagnosed ME/CFS using the Fukuda case definition, which includes a combination of broad, nonspecific symptoms; most were small studies (mean sample size of 24) of predominantly women (mean age range of 35-50 years). Study quality was assessed using the Rosendal scale, which combines PEDro scale, Jadad scoring and Delphi List, with 11 of 17 (65%) studies given a score of >60% (classified as excellent methodological quality). Given the broad range of interventions and small studies, it was difficult to reach conclusions. The only interventions that reported significant effects on fatigue or secondary outcomes were:
- One short-term RCT (eight weeks) and one small crossover RCT (n=26, four weeks) reported NADH alone or in combination with coenzyme Q10 reduced fatigue. The crossover RCT was limited by the use of an investigator-developed questionnaire to evaluate symptoms.
- One RCT of ubiquinol-10 for 12 weeks reported improvements in nighttime awakenings, but no improvement in fatigue.
- One randomized crossover study (n=10, two weeks) identified polyphenol-rich cocoa and dark chocolate improved fatigue compared to low polyphenol chocolate.
- Two pilot RCTs suggested that probiotics may improve neurocognitive function and anxiety, with one of these studies observing no overall difference in general fatigue.
- One small RCT of pollen extract (n=22, three months) reported a decrease in symptoms and overall well-being in the treatment group; however, no between group analyses were performed.
The authors identified several study limitations, including that most interventions were single, small, short-term studies, and that there was heterogeneity in participant characteristics (e.g. illness duration, BMI) and study design (1). Most studies did not control for dietary intake, which may have influenced the results. Overall, the authors concluded that there was insufficient evidence for using nutritional supplements or modified diets to improve symptoms of ME/CFS.
- A 2021 systematic review by the same research organization examining nutraceutical interventions for ME/CFS identified nine interventions (three of which were published after and not included in the aforementioned review) (2). The three additional studies all consisted of a medication (KPAX002, methylphenidate hydrochloride accompanied by a mitochondrial modulatory), which failed to show a consistent benefit on ME/CFS symptoms.
- A 2017 consensus document by the International Writing Group for Pediatric ME/CFS recommended eliminating caffeine beverages in the late afternoon and evening based on empirical evidence that excessive amounts of caffeine can cause tachycardia and agitation and contribute to sleep problems (3). Other suggestions related to consuming regular, small meals and snacks and avoiding too much fluid with meals to address symptoms of anorexia, nausea and bloating.
- A 2021 NICE guideline found a lack of evidence and lack of consensus to make recommendations for any dietary strategy for ME/CFS (4). A recommendation was made for research to examine the clinical and cost effectiveness of dietary strategies. Some general recommendations included ensuring a dietary assessment was conducted and general dietary advice was suggested, including consuming a healthy diet and strategies to minimize complications related to nausea; dysphagia; difficulties buying, preparing and eating food; and referring individuals to a dietitian who present with malnutrition or a restrictive diet.
Comments
Myalgic encephalomyelitis (formerly chronic fatigue syndrome) is a complex, chronic condition characterized by a cluster of symptoms that can include debilitating fatigue and malaise (especially worse after exertion), cognitive, immune and autonomic dysfunction, and neuroendocrine and immune symptoms (5). The lack of diagnosis for ME/CFS, which is based on described symptoms, led the Institute of Medicine to redefine the condition in 2015 as systemic exertion intolerance disease (SEID) with criteria stating that it must be due to fatigue that persists for more than six months, in addition to post-exertional malaise and unrefreshing sleep, and also include orthostatic intolerance or cognitive decline (6). The etiology of ME/CFS is unknown; the most common factors have been attributed to infectious illness, stress and exposure to an environmental toxin. The characteristics of long COVID suggest overlaps with the presentation of ME/CFS. A systematic review of 21 studies reporting long COVD symptoms identified that the three major criteria symptoms of ME/CFS (fatigue, reduced daily activity, post-exertion fatigue) and minor criteria (neurologic/pain, neurocognitive, etc.) were present in long COVID; however, few studies met the criteria of symptoms lasting six months or more (6). Guidelines for the management of ME/CFS suggest investigations to rule out other diagnoses, including checking blood levels of ferritin, folate and vitamin B12 (4).
References
- Campagnolo N, Johnston S, Collatz A, Staines D, Marshall-Gradisnik S. Dietary and nutrition interventions for the therapeutic treatment of chronic fatigue syndrome/myalgic encephalomyelitis: a systematic review. J Hum Nutr Diet. 2017 Jun;30(3):247-259. doi: 10.1111/jhn.12435. Epub 2017 Jan 22. PMID: 28111818; PMCID: PMC5434800. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/28111818/
- Maksoud R, Balinas C, Holden S, Cabanas H, Staines D, Marshall-Gradisnik S. A systematic review of nutraceutical interventions for mitochondrial dysfunctions in myalgic encephalomyelitis/chronic fatigue syndrome. J Transl Med. 2021 Feb 17;19(1):81. doi: 10.1186/s12967-021-02742-4. PMID: 33596913; PMCID: PMC7890871. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/33596913/
- Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS, Speight N, Stewart JM, Vallings R, Rowe KS. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young Individuals: A Primer. Front Pediatr. 2017 Jun 19;5:121. doi: 10.3389/fped.2017.00121. PMID: 28674681; PMCID: PMC5474682. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/28674681/
- National Institute for Health and Care Excellence. NICE guideline NG206. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome diagnosis and management; 2021. Available from: https://www.nice.org.uk/guidance/ng206/evidence
- Bested AC, Marshall LM. Review of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: an evidence-based approach to diagnosis and management by clinicians. Rev Environ Health. 2015;30(4):223-49. doi: 10.1515/reveh-2015-0026. PMID: 26613325. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/26613325/
- Wong TL, Weitzer DJ. Long COVID and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)-A Systemic Review and Comparison of Clinical Presentation and Symptomatology. Medicina (Kaunas). 2021 Apr 26;57(5):418. doi: 10.3390/medicina57050418. PMID: 33925784; PMCID: PMC8145228. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/33925784/