Nutrition for chronic pain

1. Nutrition for chronic pain Jessica Jameson MD

2. Introduction • In the US, chronic illnesses and health problems either wholly or partially attributable to diet represent by far the most serious threat to public health • Obesity and cardiovascular disease have become an epidemic • An estimated one third of all cancer deaths are due to nutritional factors including obesity

3. Introduction • Discuss the differences in our current diet and the hunter/gatherer diet • Examine the important components of a healthy diet • Discuss the role of inflammation in disease state • Discuss strategies to improve chronic pain with dietary interventions

4. Nutritional characteristics of pre and post agricultural diets • Prior to the development of agriculture dietary choices would have been limited to minimally processed wild plant and animal foods

5. Dairy pre-agricultural • Consumption of milk products would have been nearly impossible before the domestication of livestock

6. Cereals pre-agricultural • Wild cereal grains are small, difficult to harvest, minimally digestible without processing and cooking • Appearance of stone processing tools in fossil record represents a reliable indication of when and where grains began to be included • Therefore before 5-10k years ago grains consumption was uncommon

7. Cereals cont. • 85% of cereals consumed in US diet are highly processed refined grain • Prior to industrial revolution all cereals ground with stone milling and therefore contained entire contents of cereal grain • After mechanized steel roller mills in end of 19th century the nutritional characteristics of milled grain drastically changed as the germ and bran were removed in milling process

8. Refined sugars pre-agricultural

9. Refined sugars cont. • 500BC first evidence of crystalline sucrose production • Prior to this honey represented one of the few concentrated sugars-likely seasonal and studies indicate very minor component of diet

10. Refined sugar cont. • 1970s high fructose corn syrup in mass quantity became economically feasible

11. Refined sugar cont.

12. Refined vegetable oils

13. Refined vegetable oils cont. • 3 ways to produce oils from oil bearing seeds • Rendering and pressing • Expeller pressing • Solvent extraction

14. Refined vegetable oils cont. • Oils from walnuts, almonds, olives, sesame and flax seeds likely produced 6000y ago by rendering and pressing • Most early use of oils seems to have been for nonfood purposes such as illumination, lubrication, medicine

15. Refined vegetable oils cont. • Advent of mechanical expellers allowed for greater world wide vegetable oil productivity • New purification procedures allowed for exploitation of nontraditionally consumed oils such as cottonseed • New processes allowed for atypical structural characteristics • ie margarine and shortening produced by solidifying vegetable oils through hydrogenation • Hydrogenation produces trans fatty acids that are almost never found in conventional human food

16. Alcohol • Alcohol consumption in US represents minor (1.4%) contribution to the total energy consumed • Likely small contribution to paleolithic people as inability to control the process, seasonality of grapes, inability to store

17. Salt • Prehistoric people may have dipped food in seawater or used dry seawater • Inland hunter-gatherers add no or little salt to food • Currently 75% of typical daily salt intake is derived from salt added to processed foods by manufacturers • 10% occurs naturally

18. Fatty domestic meats • Body fat in wild animals is seasonal with highest levels in Sept/Oct • With animal husbandry it became possible to control what the animals ate and slaughter at a specific time • Early 19th century saw steam engine and railroad which allowed for grain harvest and transport of grain and cattle = grain fed cattle

19. Fatty meat cont. • Marbled meat has greatly increased saturated fatty acid content and lower proportion of n-3 acids and more n-6 acids • 99% of US beef is now from grain fed feedlot • 200 years ago virtually no beef produced in this matter

20. Health effects of foods in industrial era • Glycemic load • Fatty acid composition • Macronutrient composition • Micronutrient density • Acid base balance • Sodium potassium ratio • Fiber content

21. Glycemic load • Repeated consumption of high glycemic index mixed meals results in higher mean 24h blood glucose and insulin concentrations • Chronically high glucose and insulin leads to “diseases of civilization” –DM, CAD, HTN, hyperlipidemia • Mounting evidence that insulin resistance plays roll in acne, gout, PCOS, breast, colon prostate cancer

22. Glycemic load cont. • Dairy has low glycemic index but is highly insulinotropic (comparable to white bread) • In US diet 39% of total energy supplied by foods that promote elevation in glucose, insulin, VLDL, FFA

23. Fatty acid composition • Substantial evidence exists that the amount of fat is less important than the type of fat • Balance of omega 3 and omega 6 is integral in preventing chronic disease • Western diet has too little omega 3 and excessive saturated and trans fatty acids

24. Fatty acid cont. • A 20% reduction in overall mortality and a 45% reduction in sudden death after 3.5y reported in subjects with preexisting CVD when given 850mg omega 3 either with or without vitamin E • Higher intakes of omega 3 help with many inflammatory and autoimmune disease

25. Fatty acid cont. • Atherosclerosis is also contributed to by chronic inflammation • CRP is strong predictor of CVD • High glycemic diets increase CRP

26. Fatty acid cont. • 6 major sources of SFAs in US-all but one would not have existed prior to industrial revolution and animal husbandry • Fatty meats • Baked goods • Cheese • Milk • Margarine • Butter

27. Fatty acid cont. • Advent of vegetable oils significantly increased omega 6 PUFAs • Exacerbated by meat from grain fed cattle and livestock • Current ratio of omega 6:omega 3 is 10:1 • Ratio in hunter gatherers 2:1

28. Macronutrient composition • US diet-carb 51.8% protein 15.4% fat 32.8% • Current recommendation to reduce risk of CVD is fat under 30% • Hunter gatherer likely-protein 19-35% carb 22-40% • Increasing evidence that dietary protein has a cardioprotective effect

29. Macronutrient cont. • Elevated protein diet associated with lower plasma homocysteine which is independent risk factor for CVD • Population studies suggest that stroke mortality is inversely related to protein intake

30. Micronutrient density • Refined sugars are devoid of any vitamin or mineral • At least half US population fails to meet RDA for B6, A, Mg, CA, Zinc

31. Acid base balance • Typical western diet yields net acid load of 50mEq/d • Pre-agricultural diets were net base yielding • Net base diet health benefits include • Preventing osteoporosis • Prevention of age related muscle wasting • Prevention of calcium kidney stones • Prevention of HTN • Prevention of exercise induced asthma

32. Sodium-Potassium ratio • Western diet is substantially higher in sodium than potassium • 90% of sodium in our diet comes from manufactured source • Vegetable oil and refined sugar has no potassium • Displacement of vegetables and fruit by whole grains and milk reduces the potassium intake

33. Sodium-potassium ratio • Diets low in K and high in Na may underlie or exacerbate HTN, stroke, kidney stones, osteoporosis, GI cancer, asthma, insomnia

34. Fiber content • Refined sugars, vegetable oils, dairy, ETOH are devoid of fiber • Fiber depleted refined grains represent 85% of grains consumed • Soluble fiber slows gastric emptying and may help control caloric intake • Low fiber diets may effect hemorrhoids, diverticulitis, hiatal hernia

35. What does this mean for our patients?

36. What does this mean for our patients? • Increasing evidence that increasing protein is important in chronic pain patients • Protein is composed of amino acids which are crucial in building endogenous pain relievers such as endorphin, dopamine, serotonin, GABA • Protein builds muscle and cartilage • Protein activates glucagon-blocks glucose storage as fat • Protein decreases inflammation

37. Inflammation • It has been shown that the typical American diet is pro-inflammatory • Histamine, bradykinin, IL-1, TNF, free radicals and prostaglandins and thromboxane are known to activate and sensitize nociceptors • We know that many chronic diseases including chronic pain are contributed to on some level by inflammation • Anti-inflammatory medications have a roll in chronic pain, cancer, alzheimers and more • Therefore efforts to decrease inflammation will improve these conditions

38. Evidence regarding inflammation and pain • Fatty acid imbalances may actually form the foundation on which the proinflammatory state develops • Simopoulos indicates that our omega 6:omega 3 must be under 4:1 to avoid the promotion of heart disease and cancer • NSAIDs are being used in record amounts

39. Increasing Omega 3’s effects • Decreased production of PGE2 • Decrease in TXA2-platelet aggregator and vasoconstrictor • Increased production of TXA3 • Decreased LTB4-inducer of inflammation and leukocyte chemotaxis • Multiple studies confirming the decreased lymphocyte production of pro inflammatory cytokines

40. Omega 3’s • Texts and journal articles devoted to inlammatory disease with no mention of omega 3’s • USDA food pyramid – NO MENTION! • Linder et al indicates that fish oils may be more useful than ASA in suppressing chronic inflammation

41. Omega 3 dose • Kremer has studied omega 3 supplementation in RA for many years • Minimum daily dose of 3g of EPA and DHA • =10 standard fish oil capsules (180mg EPA and 120mg DHA)

42. Free radicals • May form in response to mechanical injury to tissues • Also result from air pollutants, pesticides, tobacco smoke • Readily gives up or accepts electron which is damaging to cellular structures including lipids, proteins, membranes, DNA • Final common pathway of cell injury in chemical and radiation injury, oxygen toxicity, cellular aging, inflammatory damage, tumor destruction

43. Antioxidants • Found in fruits and vegetables • US intake of these foods is remote from recommended levels • USDA recommends 3 servings of vegetables • Simopoulos suggests 7 or more

44. Antioxidants cont • Studies suggesting vit D supplementation reduces chronic back pain • Tart cherries reduce inflammation to same effect as indomethacin • EVOO has oleocanthol which has ibuprofen like activity

45. Thoughts • Main biochemical intervention for musculoskeletal pain is NSAIDS • NSAIDs act to inhibit a biochemical process acting on fatty acids that come from OUR DIET • We eat ourselves into an inflamed and painful state and then seek our passive care from doctors to intervene on our behalf

46. Final Recommendations • High protein-building block of healthy tissue • Minimal to no processed carbohydrate/refined sugar • Increased fruit and vegetable consumption • Supplementation of Omega 3’s • Decrease in Omega 6’s

47. Practical tips • Discussion about lifestyle at each visit • Diet choices • Exercise journal • If diet seems to be problematic consider dietitian referral vs patient food log • USPSTF recommends heavy counseling and behavioral therapy in regards to obesity and diet

48. Conclusion • Discussed the differences in our current diet and the hunter/gatherer diet • Examined the important components of a healthy diet • Discussed the role of inflammation in disease state • Discussed strategies to improve chronic pain with dietary interventions

49. Let food be thy medicine and medicine be thy food….Hippocrates

50. Questions?