nutrition and pain clare collins phd, bsc, dip nutr&diet, dip clin epi, advapd, fdaa professor...

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?

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

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.

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

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.

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

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

nutrition and pain clare collins phd, bsc, dip nutr&diet, dip clin epi, advapd, fdaa professor...

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