Transcript Meleger et al PMR 2014

Nutrition and eating behavior in
patients with chronic pain receiving
long-term opioid therapy
Joseph Walker III, MD
Department of Orthopedics
University of Connecticut
Prevalence of chronic pain
Background
Developed countries: 19-37%
Developing countries: 41%
Adapted from Windt et al. J Psychosom Res 2008
Objectives
Objectives
Previous studies suggest a correlation between nutrient intake and chronic
pain
However, the lack of clinical research regarding the dietary behavior of
patients with chronic pain has been noticeable
Objectives of this study
To assess nutrient intake and eating behavior in a group of patients who were
diagnosed with chronic pain and received long-term opioid analgesic therapy
Inclusion criteria
Inclusion criteria
Methods
At least 18 years old
Intractable chronic pain
Long-term opioid analgesic treatment
Exclusion criteria
Previous eating disorders
Pregnancy
Methods
Demographic and clinical data of participants
Characteristics
Value ± SD
Sample size, n
53
Men (%)
30 (57)
Women (%)
23 (43)
Age, y
54.7 ± 11.3
White (%)
51 (96)
American Indian (%)
2 (4)
Mental Health Diagnosis (%)
19 (36)
Meleger et al PMR 2014
Methods
Demographic and clinical data of participants
Characteristics
Value ± SD
Chronic Pain Diagnoses
Low pack pain ±Lumbar
Neck pain ± Cervical
Neuropathic pain (Peripheral, Central, CRPS)
Joint pain (psoriatic, degenerative)
Fibromyalgia
Poststemotomy pain
Perineal pain
Post-traumatic jaw pain
30
9
9
9
2
1
1
1
Pain Level 0-10
5.8 ± 2.2
Average Morphine equivalents, mg
226.6 ± 199
Duration opioid treatment, y
1.5-14
Meleger et al PMR 2014
Demographic and clinical data of participants
Methods
Parameter
Value ± SD
BMI, X ± SD
29.3 ± 6.1
Overweight (BMI ≥25 - <30), N (%)
14 (28)
Obesity (BMI ≥ 30), N (%)
22 (44)
Meleger et al PMR 2014
Methods
Experimental setup
Meleger et al PMR 2014
Study instruments
Pain Intensity during 6 months
Methods
Numeric rating scale and visual faces scale (Wong-Baker Faces Rating Scale)
Biosphychosocial information
Short demographic survey
Study instruments
Nutrient data
Methods
14-item Food Frequency Questionnaire (FFQ)
-Type of foods they consumed
-Quantity of those foods in relation to a medium sized portion
Nutrient calculations
Nutrient data system for research software (2010)
-Generates multiple datasets from a batch of completed FFQ
forms, including the daily nutrient intake dataset
Eating behavior
Eating behavior inventory (EBI)
-26-item self-report instrument developed to asses individual
behaviors that have been implicated in weight-loss management
Results
Weight distribution and caloric intake
Note: 6/30 men and 6/20 women reported a daily
caloric intake below 1200 calories per day
Meleger et al PMR 2014
Results
Mean individual daily consumption
Nutrient
Mean ± SD
Recommended
Carbohydrates (%)
51
45-65
Protein (%)
16.3
10-35
Fat (%)
34.1
20-35
Meleger et al PMR 2014
Results
Mean individual daily consumption
Nutrient
Mean ± SD
Recommended*
Carbohydrates (g)
(kcal)
240.6 ± 105.1
962.4 ± 420
Sugar, total (g)
125.6 ± 59.6
130
Sugar, added (g)
74.4 ± 43.0
Restrict Intake
Glycemic Load
117.7 ± 54.7
90
Fiber (g)
17.3 ± 7.5
25
Aspartame (mg)
145.9 ± 300.5
* Recommend/Guidelines from USDA Dietary Reference Intake
Meleger et al PMR 2014
Results
Mean individual daily consumption
Meleger et al PMR 2014
Results
Mean individual daily consumption
Nutrient
Mean ± SD
Recommended*
Cholesterol (mg)
266.5 ± 234
< 300
Saturated fat (g)
(%)
25.8 ± 16.8
12.3
< 16
<7
Omega-3-fatty acids (g)
1.6 ± 0.99
Prevention cardiovascular disease: >0.3
Modulation of RA pain: 2.6 -7.1 (RA)
Total trans-fatty acids (g)
(%)
2.7 ± 1.7
1.3
< 2.0
< 1.0 %
Total monounsaturated
fatty acids (g)
25.7 ± 14.6
Total polyunsaturated
fatty acids (g)
14.4 ± 8.3
(14-17g /day) men
(11-12g /day) women
* Recommend/Guidelines from USDA Dietary Reference Intake
Meleger et al PMR 2014
Results
Mean individual daily consumption
Meleger et al PMR 2014
Results
Daily consumption of fruit and vegetables
Daily Serving
Mean ± SD
Recommended*
Fruit
(5-a-day method)
1.5 ± 1.2
4-5
Fruit
(summation method)
1.8 ± 1.1
4-5
Vegetables
(5-a-day method)
1.9 ± 1.4
4-5
Vegetables (summation 1.9 ± 1.5
method)
4-5
* Recommend/Guidelines from USDA Dietary Reference Intake
Meleger et al PMR 2014
Results
Daily consumption of Alcohol and Caffeine
Daily Consumption
Mean ± SD
Recommended*
Alcohol (g)
1.6 ± 0.5
< 14
Caffeine (mg)
199.9 ± 160.8
< 186
* Recommend/Guidelines from USDA Dietary Reference Intake
Meleger et al PMR 2014
Results
Daily consumption of Tryptophan
Daily Consumption
Mean ± SD
Tryptophan (g)
0.9 ± 0.4
Meleger et al PMR 2014
Results
Daily consumption of vitamins
Mean ± SD
RDA (Men)
RDA (Women
Vitamin A (mg)
1083.8 ± 1483.1
900
700
Vitamin C (mg)
112.7 ± 72.0
90
75
Vitamin D (IU)
244 ± 208
600
600
Vitamin E (mg)
14.3 ± 13.8
15
15
Vitamin B12 (mg)
8.6 ± 10.2
2.4
2.4
Folate (mg)
436.7 ± 222.0
400
400
* Recommend/Guidelines from USDA Dietary Reference Intake
Meleger et al PMR 2014
Results
Daily consumption of vitamins
Meleger et al PMR 2014
Results
Daily consumption of minerals
Meleger et al PMR 2014
Results
Daily consumption of minerals
Mean ± SD
RDA (Men)
RDA (Women
Calcium (mg)
1111.7 ± 672.1
1000
1000
Magnesium (mg)
293.6 ± 120.4
420
320
Iron (mg)
15.2 ± 8.8
8
18
Sodium (mg)
2868.5 ± 1388.1
<2300
<2300
* Recommend/Guidelines from USDA Dietary Reference Intake
Meleger et al PMR 2014
Conclusions
Calorie intake
Our results suggest a similar percent of fat, protein, carbohydrate calorie intake
Conclusions
However, regarding type of fat intake, the participants reported greater than
recommended saturated fat and trans fat consumption compared to guidelines
Clinical conclusion
Counsel the patient on reducing saturated fat and transfat intake and to
bring more in line with guidelines
Conclusions
Vegetable intake
Conclusions
Participants consumed an approximate daily average of 2 servings of fruits
and vegetables, respectively
This is well below the suggested daily guidelines of 4-5 servings in each
category as proposed by the American Heart Association and the Dietary
Approaches to Stop Hypertension diet
Clinical conclusion
Counsel the patient on raising vegetable intake
Conclusions
Sodium Intake
Conclusions
Sodium intake was found to be significantly higher than the conservative
suggestion of 2.3 g per day
Clinical conclusion
Counsel the patient on lowering sodium intake
Conclusions
Caffeine Intake
Conclusions
All but one participant reported a higher regular consumption of caffeine
than the average consumption in Vermont
Clinical conclusion
Counsel the patient to lower caffeine intake, since there is a possible
relationship with poor sleep/insomnia
Conclusions
Omega-3-Fatty Acid intake
Conclusions
The majority of participants consumed more than the recommended
Cardiovascular protective dose of omega-3-fatty acids, but less than the
anti-inflammatory dosing found to be effective in persons with RA
Clinical conclusion
Counsel patients with RA to increase their daily dosage via fish, nuts,
and seeds
Conclusions
Vitamin and Mineral intake
Conclusions
Results from the present study indicate suboptimal intake of micronutrients,
especially vitamin D and Magnesium
Clinical conclusion
Counsel the patient to increase/balance their intake of magnesium and
vitamin D
Conclusions
Eating Behaviours
Conclusions
Our results demonstrate a pattern in average EBI scores that is very
similar to the scores for new patients entering a weight-loss
management centre
Explanations
-Participants have eating behaviours that promote weight gain
-Participants have eating behaviours that do not promote weight loss
Clinical Conclusion
Physician may wish to direct patients to weight-management
Conclusions
Artificial Sweetener Intake
Conclusions
Participants had high intake of artificial sweeteners such as aspartame
Clinical Conclusion
Consult patients with fibromyalgia or headache disorders that minimizing/
stopping this high intake may relieve their symptoms
Conclusions
Conclusions
Future Perspectives
Future Perspective
Study limitations
Small sample size
Sampling bias
Small ethnic heterogeneity
Long-term opioid analgesic therapy
Future studies
Large prospective population studies are needed to confirm our results
in patients with or without opioid analgesics
Acknowledgements
Dept. of Physical Medicine and Rehabilitation
Harvard Medical School
Boston, MA
and
Spaulding Rehabilitation Hospital
Medford, MA
Marriage and Family Therapy Program
Human Development and Family Studies
University of Connecticut
Storrs, CT
Cameron Kiely Froude, MA
Alec L. Meleger, MD
Spaulding Rehabilitation Hospital
Medford, MA
Virginia Czamowski, NP
Supported by:
Spaulding Rehabilitation Mini-Grant
FIN
Meleger AL, Froude CK, Walker J. Nutrition
and eating behavior in patients with chronic
pain receiving long-term opioid therapy.
PM&R. 2014 Jan; 6(1):7-12.