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8 Articles in Volume 16, Issue #3
CDC Issues Final Guidelines for Opioid Prescribing: PPM Editorial Board Responds
Don't Flinch From Prescribing Pain Medications!
Help Patients Achieve Diet/Weight Goals to Manage Pain
Hormone Testing and Replacement: Status Report 2016
Living With, and Managing, Chronic Pain: A Patient’s Story
Nerve Decompression Surgery Can Reverse Neuropathy of the Foot
Pulsed Electromagnetic Field Therapy: Innovative Treatment for Diabetic Neuropathy
Specialized Pharmacies Step Into Risk-Management Role

Help Patients Achieve Diet/Weight Goals to Manage Pain

A primer on how healthcare providers can use elements of nutrition and a multidisciplinary team approach to weight loss to help patients manage chronic 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.

Eating "real" rather than "processed" foods can help reduce inflammation and improve pain.

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.

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.

Gout

As noted, patients diagnosed with gout need to decrease uric acid levels in their blood. Limiting their intake of high purine foods may help to decrease their joint pain (see gout diet). According to the AMA, purine-containing foods include beer, anchovies, yeast, organ meat, legumes, meat gravies, mushrooms, spinach, asparagus, and cauliflower. Foods which may decrease inflammation and be beneficial to people with gout include dark berries, tofu, salmon, olive oil, and nuts.23

Rheumatoid Arthritis And Fibromyalgia

There are several other theories about the causes of fibromyalgia, from hormonal disturbances to stress to genetics. Fatty acids are believed to decrease pain caused by inflammation in rheumatoid arthritis and fibromyalgia.24 Essential fatty acids, like omega-3, decrease inflammatory responses. Common sources of omega-3 fatty acids include flax seeds, walnuts, cold-water fish (ie, salmon), and soybeans. Foods that may help control chronic pain in conditions such as rheumatoid arthritis and fibromyalgia include cherries, soy, oranges, peaches, asparagus, cranberries, cauliflower, and kiwi. Dairy products, chocolate, eggs, meats (beef and pork), chicken, wheat, corn, and nuts theoretically worsen inflammation and consumption should thus be decreased.

Osteoarthritis

Osteoarthritis occurs when the cushion that separates bones at the joints is lost and the bones rub together. Patients with osteoarthritis should make sure to have plenty of vitamin D and calcium in their diet.25 Food sources of vitamin D include salmon, tuna, mackerel, and milk, orange juice, and yogurt with added vitamin D. There are additional steps patients can follow to obtain more vitamin D, such as receiving more midday sun exposure and taking supplements. Food sources of calcium include milk products, beans, tofu, nuts, meats, fish, poultry, oats/grains, orange juice, soy, broccoli, turnip greens, okra, and kale.

Opioid-Induced Constipation

Nutritional health can also provide relief for constipation caused by opioid pain medications and muscle relaxants. First, it is recommended to eat a high fiber diet, which includes foods such as fruits, vegetables, whole grains, seeds, and beans. Second, one should drink about 8 glasses of water daily, and avoid drinking whole milk, coffee, and sodas as they contribute to constipation. Although caffeine is a bowel stimulant, it can also cause dehydration, which can have the opposite effect and lead to constipation. One should also reduce eating foods that cause constipation, including cheese, ice cream, whole milk, fatty meats, sugar processed foods, and pastries. Finally, one can improve digestion by eating foods like papaya and some yogurt products. There are four additional steps patients can follow to relieve constipation, including:

  • Exercising regularly
  • Reducing stress
  • Assuming a squatting position
  • Taking time for healthy elimination.

In addition to dietary recommendations, it is also recommended for patients to have a prophylactic bowel regimen consisting of a stimulant laxative with or without a stool softener while being prescribed opioid therapy.

Weight Loss Benefits Pain Management

A 5% to 10% loss in weight has been found to lower the risk of high cholesterol, hypertension, diabetes, insulin resistance, obstructive sleep apnea, and inflammation. Losing weight also improves patients’ quality of life and facilitates their ability to perform activities of daily living.26

More specifically, a 5% to 10% weight loss can result in:

  • Increase in “good” cholesterol, or HDL, by 5 points
  • Decrease in triglyceride levels
  • Decrease by 5 mmHg, on average, in blood pressure, both systolic and diastolic
  • Decrease in hemoglobin A1c (a normal level is below 6.5%) by half a point on average
  • Significant decrease in insulin levels
  • Improved sleep apnea; reduced need for a continuous positive air pressure (CPAP)

Finally, when weight loss reaches 10%, the levels of inflammatory substances circulating in the blood drop significantly.

But the problem with reducing weight in patients with chronic pain is multifaceted. Chances are patients are unable to move or exercise enough to lose weight. Medications, such as opioids, sedatives, muscle relaxants, or antidepressants, may suppress the body’s metabolism and cause weight gain. However, these co-occurring issues are both amenable to behavioral self-management interventions.

Treatment Options: Exercise, Diet, and Psychotherapy

An integrative approach that combines physical activity, nutritional education, and behavioral strategies appears to provide maximum benefit.27

A physical intervention may include a program of combined training (aerobic/resistance exercise), which includes sessions of 60 minutes (30 minutes aerobic and 30 minutes resistance) with a frequency of 3 times a week (180 minutes/week), under the supervision of an exercise physiologist or a physical therapist. These guidelines for exercise testing and prescription are recommended by the American College of Sports Medicine in the 9th edition of their book.28 Aquatic exercise may also be an effective tool for patients with obesity who have difficulties with active exercise due to knee osteoarthritis.29

A nutritional intervention may include classes on topics related to improving food consumption (a high fiber diet), reading nutrition facts on labels, learning portion control, completing a food diary, and having individual consultations with a nutritional health provider.

When reading nutrition facts on labels, patients need to be taught to understand and evaluate the information listed. The main or top section contains product-specific information such as serving size, calories, and nutrient information. The second section contains information for important nutrients including fats, sodium, sugars, and fiber. At the bottom is a footnote stating that the recommended percent of daily values is based on 2,000 and 2,500 calorie diets

A key factor in the expanding waistbands of Americans has been the super-sizing of portions, especially in prepared and fast food restaurants (Table 2). To help patients control their portions, share these 7 tips:

  • Avoid skipping meals and eat at regular intervals (3 meals a day, and 2 in-between meal snacks)
  • Use a measuring cups and food weight scales
  • Develop some imaging techniques to recognize recommended serving sizes (eg, 3 oz. of lean meat=1 deck of cards)
  • Understand the difference between serving size (recommended food measurement listed on nutrition facts labels) versus portion size (amount of food chosen, which could be more or less than a serving)
  • Use portion-control plates or smaller dinner plates
  • Develop good “eating out” habits (check the menu beforehand, know the healthiest options)
  • Plan meals

When using a dietary record approach (daily food diary), have the patient record the amount of food and beverages at the time they are consumed in order to avoid reliance on memory. If available, a nutritionist can review the food diary with the patient to monitor progress. If one is not on staff, refer the patient to an online food tracker.30 [Editor’s Note: Most insurance plans under Obamacare and some private insurance companies offer weight-loss and wellness programs at businesses, schools, and in communities—but the method they use is up to the individual plans.]

Psychological interventions often focus on cognitive and behavioral strategies for weight management, with research demonstrating that behavioral interventions tend to be more effective than cognitive interventions.31,32 Strategies might include patient self-monitoring, stimulus control, goal setting, problem-solving, and identification of antecedents, behaviors, and consequences. Other than medication and surgery, cognitive behavioral therapy (CBT) has been shown to be the most effective behavioral treatment for weight loss.

Psychological intervention may include the assessment and diagnosis of psychological problems most commonly associated with obesity such as depression, body image concerns, and anxiety along with the provision of support groups and short-term individual psychological therapy as recommended. Data on the long-term effects of these strategies is absent. However, this does not mean that obesity is resistant to psychological interventions or that they are ineffective.31,32

Multidisciplinary Weight Management Programs

Not everyone is lucky enough to be able to attend a multidisciplinary weight management program. Primary care providers are the front line practitioners of the obesity epidemic, but may be too busy to counsel patients on weight loss options, focusing instead on other treatable conditions, such as hypertension and diabetes.33,34

In the authors’ opinion, primary care providers can develop a strategy for offering weight control programs that focus on motivational interviewing and working with members of an interdisciplinary team—including psychologists, nutritionists, and pain specialists when caring for patients with “lifestyle imbalances.”

An integrative approach does present its challenges, including the contentious nature of sharing professional roles and expertise while also planning, decision-making, and delivering quality patient care within complex contexts. To work effectively in an interdisciplinary team, the leader of the team, usually a primary care provider, needs to establish a clear direction and vision, while listening and providing support and supervision to the team members.35

Motivational interviewing refers to a counseling approach that facilitates and engages the patient’s intrinsic motivation to change behavior.36 It is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence by consciously or unconsciously weighing the pros and cons of change versus not changing.37 The weighing process is not always necessarily conscious as some people are unaware of their self-control states.

In order for a provider to be successful at motivational interviewing, the provider should master four basic interaction skills:

  • The ability to ask open-ended questions
  • The ability to provide affirmations
  • The capacity for reflective listening
  • The ability to periodically provide summary statements to the patient.

Motivational interviewing is non-judgmental and non-confrontational. It focuses on the present and taps into the patient’s personal values. The main goals of motivational interviewing are to engage patients, elicit change talk, and evoke motivation to make positive changes. Ultimately, practitioners must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation.

Summary

It has been estimated that the U.S. will be home to 65 million more obese people by 2030, which leads to 8 million cases of type 2 diabetes and an additional 6 million cases of heart diseases/strokes if providers continue to postpone intervention. However, the “solution to our nation’s health crisis and obesity epidemic does not seem complicated” as proclaimed by Dr. Hyman and as delineated in this primer.1

Last updated on: January 15, 2019
Continue Reading:
An Anti-inflammatory Diet For Pain Patients

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