Transcript Document
NUTRITION
and PAIN
Clare Collins
PhD, 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 antiinflammatory 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
Pain and nutritional status
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
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
Top weight loss tips
1.
2.
3.
4.
5.
6.
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Eat breakfast
Reduce number of times you eat
Reduce portion sizes
Change types of food and drinks
Plan meals and snacks ahead
Eat more fruit and vegetables
Count/ record kilojoules/Calories
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
Poor sleep affects your
hormones
Growth
Hormone
Cortisol
Antagonise glucose
insulin response
Leptin
Ghrelin
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 Collins
PhD, 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