Help Patients Achieve Diet/Weight Goals to Manage Pain
Mother Nature is the best pharmacist and food is the most powerful drug on the planet,” wrote Mark Hyman, MD, in an article on the decline of the modern American diet.1 The problem today, he noted, is that most of the food we eat is not “natural,” but rather “industrial:”—it is over-salted, sugared, processed, and high in calories.
Why does this matter to pain practitioners? It matters because what we eat equates with how we fuel our body—and when a person eats a poor diet, over a lifetime, their body begins to break down. This deterioration includes increased rates of metabolic disorders (hypertension, type 2 diabetes, cardiovascular disease, obesity), musculoskeletal problems, and autoimmune diseases.
Therefore, the roadmap to health is simple, noted Dr. Hyman, “eat real food, practice self-love, imagine oneself well, get sufficient sleep, and incorporate movement into your life.”1 In the case of pain patients, eating a healthy diet may reduce the progression of their disease and their pain.
This article will review how diet and weight affect pain and will describe what constitutes a more nutritious (and less inflammatory) diet. It will also suggest a multidisciplinary team approach to help patients lose weight.
How Does Weight Affect Pain?
America is currently battling an obesity epidemic. According to the Centers for Disease Control and Prevention (CDC), nearly one-third of U.S. children and about two-thirds of U.S. adults are overweight or obese and are at increased risk for musculoskeletal disease.2 The CDC defines risks based on a person’s body mass index (Table 1).
Over the past few decades, Americans have witnessed a shift to a higher norm with reference to weight. For instance, the first lineman on an American football team to weigh over 300 pounds was William “The Refrigerator” Perry (355 lbs.), who played in the National Football League (NFL) in the 1980-90s. Today, the average weight of every lineman in the NFL is 355 pounds, and players tend to have a life expectancy of approximately 57 years compared with 78.8 years for the general public. Recognizing this trend, the American Medical Association (AMA) officially proclaimed obesity to be a disease in 2013.3
Healthcare claims have shown the co-prevalence of pain and obesity to be as high as 30%.4 These high rates of co-occurrence are often associated with a sedentary lifestyle that leads to decreased quality of life, emotional distress, increased disability, and shortened lifespan.
The medical literature suggests that there is a linear relationship between weight and frequency of musculoskeletal pain. Rates of neck, back, hip, knee, and ankle pain have been found to be significantly higher in obese individuals.5 However, a causal relationship remains unclear.
Similar to the chicken or the egg debate, it is yet unknown whether obesity causes pain or vice versa.6 Obesity is hypothesized to lead to knee and low back pain because of excess mechanical stresses.7,8 Messier et al showed that for each pound of body weight lost, there was a 4-pound reduction in the stress on the knee joints.9
In addition to creating mechanical stress, fat functions much like an organ that secretes chemicals, which affects blood pressure and cholesterol. In fact, adipose tissue is a major source of inflammatory mediators such as cytokines and chemokines.10 Inflammatory markers such as interleukin (IL)-6 and C-reactive protein (CRP) are significantly related to percent of body fat and insulin sensitivity.11 Where the fat is deposited also matters. Visceral abdominal adipose tissue is more metabolically active and releases greater amounts of pro-inflammatory and insulin-resistant substances than other adipose tissue.12
Obesity also has been associated with thoracic spine, neck, and upper extremity pain. When it is present in conditions such as fibromyalgia, migraines, and headaches, obesity also exacerbates pain due to its pro-inflammatory state.13 Chronic pain may also result in obesity because it leads to physical inactivity, especially in the elderly.14,15 Thus, the reciprocal should be true—weight loss can help reduce chronic pain. For example, one study found that more than a 10% loss of body weight resulted in a 50% decrease in knee osteoarthritis in patients diagnosed with obesity (body mass index >35).16
How Does Nutrition Affect Pain?
A nutritional approach to pain management involves making changes to a patient’s diet to prevent pain or promote the relief of inflammation as part of a comprehensive pain management strategy.
Back and joint pain, rheumatoid arthritis, fibromyalgia, and osteoarthritis are affected by diet. Joint pain can be caused by gout, which is the result of urate crystal deposition in the joint. Rheumatoid arthritis occurs when the body’s immune system attacks the joints, which causes an inflammatory response and subsequent pain.
Patients who suffer from chronic pain may have stumbled upon any number of “pain-lowering” diets while surfing the Internet. These include the anti-inflammatory diet,17,18 the high-protein-intake diet,19 and assorted vegetarian diets.20,21 However, there continues to be no standard guideline for a nutritional health plan to address pain—and one diet does not fit all pain conditions.
Researchers have highlighted the advantages of certain foods when added to a daily diet and have suggested avoiding foods thought to contribute to chronic pain. Below is a brief overview of some of the more common pain conditions and “recommended” diets. For a more comprehensive review of diets for pain, please refer to our website at www.practicalpainmanagement.com.
Basic Nutrition Principles
A basic principle of nutritional health is to eat food from each of the basic food groups every day. The Food Guide Pyramid (Figure 1), introduced by the US Department of Agriculture in 1992, was divided into 6 food groups. Because nutritional health experts believed the original pyramid was misleading and hard to understand, the food pyramid was then updated in 2005 to Mypyramid.gov.22 The Mypyramid.gov movement was eventually replaced by MyPlate in 2011, which was developed by First-Lady Michelle Obama’s anti-obesity team and federal health officials.22 The plate is split into 4 slightly different-sized quadrants, with fruits and vegetables taking up half the space, and grains and protein making up the other half. Patients are recommended to fill at least half the grain space with whole grains. A smaller circle sits beside the plate for dairy products.