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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
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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
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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
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Outline
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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:
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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
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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
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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
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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
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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
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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
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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
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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
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Outline
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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