NUTRITION and PAIN

1. 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

2. 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

3. 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?

4. Yes

5. 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

7. 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

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

9. 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

10. 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

11. 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)

12. Nutrient requirements in chronic pain • Most research on pain perception and pain assessment has been on Omega 3 (fish oil) supplements

13. 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)

14. 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.

16. 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.

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. Subjective Global Assessment

24. 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

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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.

33. 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

34. Top weight loss tips • 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

35. 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.

36. 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

37. 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

38. Eat your way to better sleep

39. Poor sleep affects your metabolism

40. Poor sleep affects your hormones • Growth Hormone • Cortisol • Leptin • Ghrelin Antagonise glucose insulin response Antagonise appetite regulation

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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