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NUTRITION and PAIN
Clare CollinsPhD, BSC, Dip Nutr&Diet, Dip Clin Epi, AdvAPD, FDAA
Professor in Nutrition and Dietetics
NHMRC Career Development Award
Research Fellow
School of Health Sciences, Faculty of Health
The University of Newcastle
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Does nutrition matter?
Does pain change your nutrient requirements?
Does what you eat matter when you’re in pain?
Does being in pain affect what you choose to eat or drink?
Does being in pain limit choices of foods that can be accessed independently?
Yes
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Nutrition and Pain
Dealing with pain can be a higher priority than eating
Pain can override hunger signals Accessing food supplies can be too painful to
bother Too painful to stand to cook or prepare food Too painful to shop Too painful to eat Too many side-effects from medications for food to
be enjoyable Alternatively, food may be the only enjoyable thing
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Nutrition 101
Food = macronutrients + micronutrients + water Macronutrients; protein, fat, carbohydrate,
alcohol, fibre Fat – can be saturated, polyunsaturated or
monounsaturated Omega-3 fatty acids are polyunsaturated fats that
cannot be made by the body
Micronutrients (vitamins, minerals, phytonutrients) Some complimentary & alternative medicines (CAM)
contain phytonutrients
Diet quality and pain
Diet quality is a measure of nutritional adequacy and adherence to National dietary guidelines
Lower diet quality predicts morbidity and mortality (Wirt 2009), especially CVD mortality and in males
The Australian Recommended Food Score (ARFS) is a diet quality index and has been applied to women in the Australian Longitudinal Study on Women’s Health (ALSWH)
Higher ARFS means regular consumption of a greater variety of healthy food items, esp fruit and vegetables
Wirt A &Collins CE. Diet Quality. What is it and does it matter? Public Health Nutrition 2009; 12(12), 2473 –92
Australian Longitudinal Study on Women’s Health SF36 Scores in ≈9700 mid-aged
women by quintile of Australian Recommended Food Score(1= poorest diet quality, 5 = highest diet quality)
SF36 component (Scored 0-100) 1 2 3 4 5
Mental health index 70.9 74.0 74.2 75.3 77.2
Role emotional 77.6 81.4 80.9 82.4 84.5
Social functioning 80.0 83.2 82.7 84.3 84.8
Vitality 53.2 57.3 57.2 59.7 61.8
General health perceptions 67.1 71.4 71.8 74.1 75.3
Pain index 66.6 70.5 69.5 70.9 71.8
Role- physical 72.1 77.3 76.0 77.7 78.9
Physical functioning 78.0 82.5 82.9 83.9 85.0
Nutrient requirements in chronic pain
Most research on pain perception and pain assessment has been on Omega 3 (fish oil) supplements
Omega 3 fats in chronic pain
Fat quality can influence synthesis of pro or anti-inflammatory cytokines
Omega 3 fats can increase synthesis of anti-inflammatory cytokines and block synthesis of pro-inflammatory cytokines
For fish oil supplements, 11 of 16 studies used a dose of EPA/DHA > 2.7g omega-3s per day
Increase omega-3s from oily fish (salmon, sardines), canola oil & marg, linseed & flaxseed, walnuts
Reduce polyunsaturates (sunflower & safflower)
Omega 3 fats in chronic pain
Supplementation with Omega-3s for at least 3 months improves some pain outcomes:- patient assessed pain duration of morning stiffness number of painful or tender joints use of non-steroidal anti-inflammatory
medication
Goldberg & Katz. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain 2007; 129, 210–223.
Outcomes from omega 3s taken for >5 months
Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain 2007; 129, 210–223.
Amino Acids and pain tolerance
Some evidence that increasing of specific amino acid intakes can help
When administered to patients with chronic pain, D-phenylalanine alleviated the long-standing pain within 2-3 days
Tryptophan-enriched diets found to increase pain tolerance in chronic pain
Watch this space!
Seltzer, Marcus, Stoch. Perspectives in the control of chronic pain by nutritional manipulation. Pain, 1981. 11(2): p. 141-8.
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Pain and appetite
Patients with pain commonly report eating less during acute pain episodes
If this occurs frequently, it can contribute to risk of malnutrition
Chronic pain can increase protein-energy malnutrition risk, or increase risk of excessive weight gain, or both (i.e. sarcopenic obesity)
To counter malnutrition you may need to take a close look at protein requirements and the nutritional adequacy of overall food patterns
Pain and nutritional status
Malnutrition Screening
The malnutrition screening tool (MST) can be used to help identify those at increased risk of malnutrition
You can assess presence of malnutrition using subjective global assessment (SGA)
Identify specific issues that increase the risk and put strategies in place to deal with them
Review regularly for changes in nutritional status
Food intake and quality of life can be improved when you know more about these risk factors
Screening can be routine
Refer those at risk for an enhanced primary care plan
5 allied health visits per year
Accredited practising dietitian and physio
Find an APD www.daa.asn.au
Subjective Global Assessment
Muscle strength and pain
Decreased physical activity leads to loss of lean body mass
This reduces resting and total energy expenditure
If inflammation and obesity co-exist there is additional disruption to muscle structure
Protein supplementation RCTs Limited quality RCT interventions to date Campbell assessed protein requirements
during 14wk resistance training in elderly (n=29, mean age 66y)
RCT with 0.8g pro/kg (all food provided) in sedentary vs resistance exercise
Found leg strength increased (32-36%), as long as elderly were in positive protein balance (>0.8g/kg)
Campbell, et al. Dietary protein adequacy and lower body versus whole body resistive training in older humans. J Physiol. 2002; 542(Pt 2): 631-42.
Nutrition interventions to date
RCT in 11 men, aged 61-72 years 12 wk resistance training vs. sedentary All received protein-energy
supplements (560kcal, 12 grams protein)
All gained muscle strength, but not mass
No effect of dietary supplement
Meredith et al, J Am Geriatr Soc 1992; 40(2): 155-62
Note: 1 cup milk or 3 egg white or 50g lean meat = 10g pro
Identifying Nutrition Needs
Any current diet restrictions or nutrition support
Pain medications that impact on appetite, thirst, nausea, vomiting or bowel function
Ability to chew, swallow and self-feed Food likes and dislikes Ability to shop and cook
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Medication side-effects Medications for pain can also
negatively impact on nutritional status due to side effects
constipation, nausea, appetite changes, dry mouth, urinary retention, respiratory depression
These can be managed give basic advice or refer to an APD
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain
Omega- 3s Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Body weight and pain Being overweight is an important predictor
of painful conditions, especially lower back pain
For those experiencing chronic pain, it is common to perceive that weight affects pain levels
But not pain affecting weight
Pells, J.J., et al., Moderate chronic pain, weight and dietary intake in African-American adult patients with sickle cell
disease. J National Med Assoc, 2005. 97(12): p. 1622-9.
Nutrition in Weight loss
Aim for 5–10% wt loss to improve health Waist reduction = fat loss = inflammation Reduce energy intake by 2000kJ/day to
lose 0.5 kg/wk Protein to conserve muscle mass (1g/kg) Nutritionally adequate (meet
Recommended Dietary Intakes) May need a daily multivitamin if very low
level of activity
1. Eat breakfast2. Reduce number of times you eat 3. Reduce portion sizes 4. Change types of food and drinks5. Plan meals and snacks ahead6. Eat more fruit and vegetables 7. Count/ record kilojoules/Calories
Top weight loss tips
Weight loss in chronic pain
The combination of dietary restriction and exercise to achieve weight loss has been shown to improve self-reported physical function and pain levels in oestoarthritis
Being able to move freely without pain improves a person’s ability to shop, cook and feed themselves with enjoyment
Messier, S.P., et al., The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale. BMC Musculoskelet Disord, 2009. 10: p. 93.
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Pain and sleep
Pain that keeps people awake can impair sleep quality and impair glucose tolerance, secondary to an altered hormonal response
This increases the risk of type 2 diabetes
Eat your way to better sleep
Poor sleep affects your metabolism
Growth Hormone
Cortisol
Leptin Ghrelin
Poor sleep affects your hormones
Antagonise glucose insulin response
Antagonise appetite regulation
Growth Hormone Released during sleep and exercise Lowers blood sugar levels Sleep interruption reduces GH
Cortisol Cortisol is the "stress hormone" It increases blood pressure, blood
sugar levels & has an immunosuppressive action
Leptin Leptin signals satiety to brain, ie. tells you to stop
eating Leptin is produced by adipose tissue and binds to
appetite center of the hypothalamus Bottom line: “poor sleep = impaired leptin =
increased appetite!
Ghrelin Lack of sleep produces ghrelin, which
stimulates appetite and decreases leptin Ghrelin increases before meals and
decreases after meals Gastric bypass surgery dramatically lowers
ghrelin levels
But wait, there’s more!Tired People ...
Make poor food choices Use food to stimulate
themselves to stay awake …or use caffeine Too tired to plan ahead Those with chronic sleep
problems are more likely to be insulin resistant and to develop type 2 diabetes
Have sleep friendly eating habits
Regular meals and snacks Moderate sized meals Some sleep friendly
protein and carbohydrate Avoid caffeine from
afternoon onwards No alcohol
Eating difficulties can trigger poor sleep Agitation can be caused by hunger “On-the-move” food eg cups with a
lid or drink bottles with a straw or finger food
Distraction at mealtimes, eg a Video, TV or music
MiloTM has been reported to be calming prior to bedtime
Feed bigger meals early in the day as likely to go to bed early
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain
Omega- 3s Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Putting it all together the ideal intervention
First do no harm Lose body fat Optimise lean body mass Enhance exercise performance Suits existing medical problems Reduce inflammation Protect from oxidant damage Be palatable Be affordable Be easy to prepare Be sustainable
Putting it all together the ideal DIET intervention
Omega 3 supplements >2.7g/day Fat <8% saturated Protein 1g per kg and less than 1.6 Carbs make up the remainder Reach recommended vitamins and
mineral intakes Water + fluids about 2 litres Fibre 25- 30 gram/day
Outline Does nutrition matter? Ways in which pain and nutrition interact Nutrient requirements in chronic pain Pain and malnutrition risk Medication and nutrition related side-effects Pain and weight change Pain and sleep Putting it all together Summary
Summary Nutrition does matter Pain can limit your food intake or food choices Omega 3 fatty acid and protein requirements
are increased in chronic pain Pain increases risk of malnutrition, obesity and
sarcopenic obesity Need to manage the nutrition related side-
effects of pain medication Aim to improve sleep quality Refer to an Accredited Practising Dietitian or
lobby to have one funded to join your team
Summary
Research in the area of nutrition and pain is limited
Studies are required in order to build an evidence base for effective dietary interventions to support people experiencing pain
Be proactive by linking nutrition advice to pain management
Questions
Clare CollinsPhD, BSC, Dip Nutr&Diet, Dip Clin Epi, AdvAPD, FDAA
Professor in Nutrition and Dietetics
School of Health Sciences, Faculty of Health
The University of Newcastle
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