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17 Articles in Volume 20, Issue #1
20/20 with Lynn Webster, MD
Correspondence: Opioid-Induced Hyperalgesia; Pain Care in Older Adults
Don’t Discount the Role of Diet for Chronic Pain Relief
Editorial: Why Haven’t There Been More Breakthrough Analgesics?
Gasping for Air: Sleep-Disordered Breathing and Chronic Opioids
How can botulinum toxin be used in chronic pain syndromes?
Inside the Potential of Peripheral Kappa Opioid Receptor Agonists
Neurodestructive Interventions for Cancer Pain
Obesity and Pain Care: Multifaceted Considerations for Treatment
Obesity and Rheumatoid Arthritis: What Clinicians Should Know
Sickle Cell Pain Crisis: Clinical Guidelines for the Use of Oxygen
The Complexity of Sickle Cell Pain: An Overview
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
The Rapid Rise of Non-Opioid Pain Policies
Treating Pain by Overcoming Communication Barriers
Visual Artists Tackle What Pain Looks Like
Will 2020 Be the Year of Patient Education?

Obesity and Pain Care: Multifaceted Considerations for Treatment

An integrated treatment approach for these comorbid conditions includes better sleep, exercise, and diet. Plus, how osteopathic manipulation can have a positive impact.
Pages 40-44

The incidence of obesity has risen rapidly during the past several decades, and it has been accompanied by a likewise incidence of the increase in chronic pain and prescription opioid use. Combined, these two destructive epidemics may be contributing to a larger, less discussed public health crisis. The proportion of US adults considered to be obese has increased from 15% between 1976 and 1980 to 40% in 2015 to 2016.1 Obesity is associated with an increased risk of diabetes, cardiovascular disease, and cancer and is responsible for approximately 380,000 deaths annually.2

The increase in the prevalence of obesity has been accompanied by a rise in the prevalence of chronic pain. Between 1998 and 2014, the percentage of US adults reporting pain increased from 21.4% to 34.9% among men, and from 30.4% to 41.5% among women. In 2015, 25.3 million adults reported chronic daily pain.3 A 2011 Institute of Medicine Report (Relieving Pain in America) stated that obesity is one of five major contributors to chronic pain.4

Obesity raises risks for numerous conditions associated with chronic pain, including osteoarthritis, low back pain, diabetic neuropathy, fibromyalgia, and migraine.5-7 Obesity and chronic pain adversely influence each other,8 with obesity increasing inflammation and biomechanical stress on joints, changing pain tolerance, and other factors. Body mass index (BMI) is positively related to chronic pain.9 In fact, obesity may be associated with lower pain tolerance because weight loss has been shown to improve pain sensitization.10

Concomitant with the increase in obesity, there has been a dramatic increase in prescription opioid use in recent years. While opioids were previously limited to end-of-life care, post-surgical care, and acute pain, prescription opioids have been increasingly used for chronic pain, with usage rates quadrupling between 1999 and 2010.11,12 At the population level, obesity may be responsible for 14% of the prescription opioid use.13 This trend has also contributed to increased levels of opioid dependence and overdose deaths.14 To effectively mitigate the opioid crisis, obesity’s consequences cannot be overlooked. Therefore, treatment modalities and approaches must incorporate the mind, body, and spirit of the individual, as well as the community in which they live.

To effectively mitigate the opioid crisis, obesity’s consequences cannot be overlooked. (Image: iStock)

Considerations for Patients Aiming to Reduce Obesity and Chronic Pain

The Impact of Leisure Choices

Device Use: Electronic devices such as smartphones and tablets are becoming ever-present but use of these devices may have more implications than we realize, affecting both sleep and food choice. Sleep plays a large role in a variety of repair processes and hormone regulation.15,16 A lack of sleep, as well as an excess of it, disturbs these processes.17,18 In a study conducted by Taheri, et al,17 the number of people with an average nightly sleep of less than 7.7 hours correlated with a higher BMI. Taheri’s team then measured hormone levels in individuals with varying hours of sleep. Participants who had a short sleep duration also had an increase in ghrelin, an appetite stimulant, and a decrease in leptin, an appetite suppressant.

In areas of the world with accessible, high-calorie foods, such as the US, caloric intake exceeds energy expenditure resulting in weight gain, which can lead to obesity. Possibly compounding this is the increased use of electronic devices, especially before bed. Electronic device use has recently been shown to negatively affect both sleep duration and quality in children and adolescent – with a stronger negative correlation between portable electronic use and sleep duration compared to non-portable electronic device use.19 Another study found that simply having a portable device in the bedroom may be more harmful to sleep than nonportable devices.20

Additionally, screen time not only increases obesity risk due to poor sleep, but it also negatively impacts dietary choices especially for youth, in favor of low nutritional quality foods and beverages.21 An inverse relationship exists 

between increased screen time and fruit and vegetable consumption as well.21 These findings not only demonstrate a direct link between electronic devices and the obesity epidemic, but also the impact electronics are having on nutritional status as a whole (see more on Food Choice below).

Recreation: Nonmetropolitan areas with increased numbers of built, natural, and social environments per capita have been found to have statistically significant decreased prevalence of obesity in adults and increased physical activity.22 By increasing recreational opportunities, communities can work to combat obesity from a multifaceted approach that decreases screen time, increases physical activity, improves sleep patterns, and strengthens social connections. The role of recreation is further exemplified by the fact that for adolescent boys, outdoor aerobic recreational playing is more effective at achieving weight loss than indoor aerobic treadmill exercise. Additionally, this outdoor play is more effective at increasing serum orexin A in this same population.23 (Orexin A is associated with energy expenditure as well as sleep and arousal systems, and increased orexin A is associated with protection against obesity.24

Overall, time spent outdoors is not only beneficial for weight loss but also for social connectedness and well-being. A group of 99 veterans who participated in an extended group-based outdoor recreational experience for 4 to 7 days, for instance, reported significant positive effects on psychological well-being, social functioning, and life outlook.25

The Impact of Food Choices

Food Swamps: Although the origin of the obesity epidemic is multifactorial, the way in which communities are organized seems to play an important role in obesity management. It comes as no surprise that poor eating habits contribute to the development of obesity and related comorbidities. However, these poor eating habits are not solely due to limited access to fresh food. Other food environments, such as food swamps, can also predispose a population to increased rates of obesity, especially in counties with greater income inequality and decreased mobility.26 (A food swamp is an area with a high density of establishments selling high-calorie fast-food and junk food relative to healthier food options.) Surprisingly, food swamps play a greater role in obesity development than food deserts, that is, areas with limited access to affordable and nutritious food.26

A food swamp contributes to the obesity epidemic not only because of its poor food options, but at the cellular level, these food items are often inflammatory in nature and induce oxidative stress, which can deregulate homeostasis and potentially exacerbate any chronic pain condition or inflammatory process. Patients with chronic pain undergoing long-term opioid therapy are more likely to experience obesity, exhibit deficient nutrient intake, and display poor eating behaviors, especially during pain episodes, further exacerbating this issue.27,28

Gluten: One source of inflammation from fast-food restaurants that is also prevalent in the Western diet is gluten. Fast food choices have disproportionately high fat, bread-based meals, which, in mice, alter thermogenesis in adipocytes, ultimately leading to increased weight gain and increased fat deposits.29 In mice models, four experimental diets of the same energy intake were fed to mice:

  • a control-standard diet (CD)
  • a CD added with 4.5% of wheat gluten (CD-G)
  • a high-fat diet (HFD)
  • an HFD added with 4.5% of wheat gluten (HFD-G).

After an 8-week feeding period, body weight, fat deposits, and key biomarkers were recorded. Compared to their respective controls, the mice in CD-G and HFD-G exhibited increases in both body weight and fat deposits. When samples of adipocytes were cultured and analyzed, the HFD group that also received gluten had reduced levels of adiponectin, peroxisome proliferator-activated receptor (PPAR)-α, PPARγ, and hormone-sensitive lipase compared to the HFD group that was not fed gluten. Less adiponectin affects both energy expenditure and insulin sensitivity by reducing its effects on increased fatty acid oxidation and glucose uptake into skeletal muscle.30 Adiponectin has also been shown to combat the lipotoxic effects of a high-fat diet.31 PPAR-α, another regulator of homeostasis and of gene expression for fatty acid oxidation, is anti-inflammatory and has been used to treat dyslipidemia in the form of fibrates, a PPAR-α agonist.32 Furthermore, the CD-G group had increased levels of interleukin 6, an inflammatory cytokine, compared to the CD group.29 These results have not yet been replicated in humans. However, the literature does support connections between gluten and inflammation in humans,33 and more research is being done.

Additionally, for patients with gluten-induced neuropathy, proper diet and access to gluten-free foods is essential for the management of their neuropathic pain. Thus, proper nutritional intake is not only essential for reducing obesity rates and risks in these patients, but also for reducing pain and opioid use.34

There is a wide range of techniques that adjust the body to optimize its functioning and self-healing properties. (Image: iStock)

Osteopathic Manipulative Medicine for Obesity-Related Pain

Osteopathic manipulative treatment (OMT) is a set of techniques based on four tenets:

  • the body is a unit, and the person is a unit of body, mind, and spirit
  • the body is capable of self-regulation, self-healing, and self-maintenance
  • structure and function are reciprocally interrelated
  • rational treatment is based on the understanding of the above principles.


There is a wide range of techniques that adjust the body to optimize its functioning and self-healing properties by affecting the muscles, ligaments, bone placement, blood and lymphatic vessels, and CNS flow.

The Musculoskeletal System

Few studies have been conducted in which OMT targeted treating obesity, mainly due to the large role lifestyle outside the clinic plays on weight management. However, multiple research articles have explored the use of OMT on low back pain. Many patients who are obese also experience low back pain due to the added weight and stress placed on the body’s biomechanics as the lumbosacral region of the spine transitions from a lordotic lumbar curve to a kyphotic sacral curve. As pain clinicians know, low back pain is one of  

the most common causes of chronic pain, with opioids being the main medication prescribed to manage that pain.36 However, low back pain may be effectively addressed using OMT as a safe and non-pharmaceutical alternative to opioids.37-39 In addition to providing specific strengthening exercises and education on spine safety, OMT has been shown to decrease chronic low back pain and to increase mobility of the thoracic spine in obese patients compared to those who only received the exercise and education.37 Techniques used by Vismara, et al,37 included thoracic high velocity low amplitude (HVLA) to increase mobility of the thoracic region, cranial techniques, and myofascial release. Cranial techniques focus on the mobility of the cranium as well as the dura mater, which also attaches onto the sacral vertebral segment of S2 in the low back region. Myofascial release is another OMT technique that affects nerve function as nerves travel and are housed within the vast network of connective tissue.40

The Endocannabinoid System

OMT has benefits beyond the MSK system for obese patients. In obese individuals, there is increased endocannabinoid tone in peripheral tissues and dysregulation of the endocannabinoid system.41 Endocannabinoids are not only involved in energy metabolism, but also appetite, pain control, and mood regulation.41 Rimonabant, an anti-obesity drug, was developed to help obese patients with appetite regulation via the endocannabinoid system. Ultimately the psychiatric side effects of rimonabant led to its removal from the market, but the research for this drug, both premarket and postmarket, provided greater understanding of the role of blocking or downregulating the endocannabinoid system and its relationship to weight loss.

Inadvertently, the side effects of the medication illuminated the role that blocking the endocannabinoid receptor, CB1, has on mood and mental health.42 OMT may potentially provide a nonpharmaceutical option that impacts the endocannabinoid system without the negative side effects seen with pharmaceuticals.

As previously stated, there are limited studies exploring the relationship between OMT and obesity. However, one recent study found that pain biomarker levels are altered after OMT.43 The pain biomarkers measured were: β-endorphin (βE), serotonin (5-hydroxytryptamine [5-HT]), 5-hydroxyindoleacetic acid (5-HIAA), anandamide (arachidonoylethanolamide [AEA]), an endocannabinoid, and N-palmitoylethanolamide (PEA), which increases the activity of anandamide. During the study, blood samples were collected for 5 consecutive days. On Day 4, participants received OMT directed to the specific somatic dysfunction found in their MSK system.

Areas of somatic dysfunction include sites of muscle hypertonicity, tenderness, and joint restriction.43 These areas were treated with muscle energy, soft tissue, strain-counter-strain, and articulatory system treatment techniques. Immediate post-treatment blood samples showed increases in βE and PEA levels and a decrease in AEA levels. The biomarker levels sustained their changes from baseline after 24 hours. Additionally, participants reported on an 11-point scale decreased levels of stress from baseline to Day 5 post-treatment, which corresponded to the change in PEA from baseline to ٢٤ hours post-treatment.

The overall findings of this study provide valuable insight into the role that OMT can play at the biochemical level in helping patients to manage not only chronic pain but also obesity. The decreased levels of AEA lead to a decreased activation of the endocannabinoid system, which may have greater downstream effects on appetite suppression than currently understood, ultimately providing a manual approach to impacting the metabolic system. The increased levels of PEA, an endogenous anti-inflammatory molecule, and beta endorphin, an endogenous opioid neuropeptide, after OMT show the biochemical impact that OMT provides for pain management beyond musculoskeletal alignment.43


Overall, losing weight is a process that takes time. While losing weight, patients who are obese may still experience pain from being overweight as well as experience new types of pain as they exercise. Recommending OMT for patients may provide a beneficial addition to any weight regimen and, unlike many medications used for pain, does not have addictive side effects.

As the medical community faces two major health crises involving opioids and obesity, the coalescence of these crises must be appreciated. People who are obese experience higher rates of chronic pain, which contributes to the increase in opioid prescription use. Therefore, to combat the rise in opioid use, clinicians must also tackle the increasing prevalence of obesity. By addressing sleep, exercise, diet, and decreasing screen time, it may be possible to make appreciable change at both the individual and population levels. Additionally, a comprehensive treatment plan including OMT can help to address these issues.

Guiding individuals to a healthy BMI is difficult as not all the components are in the provider’s control; some may be environment-dependent. However, providers can educate patients on how to modify environmental and physiologic factors in an effort to curtail the prevalence of obesity, chronic pain, and ultimately opioid use.

Last updated on: February 4, 2020
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Obesity and Rheumatoid Arthritis: What Clinicians Should Know
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