Pauline Anderson

September 28, 2016

SAN ANTONIO — Just as the American Heart Association and American Diabetes Association have developed dietary recommendations related to heart disease and diabetes, the American Academy of Pain Management — now the Academy of Integrative Pain Management (AIPM) —  should soon also have targeted dietary recommendations.

"This is something that we as a group want to have out by the next annual meeting, if not sooner," said Robert Bonakdar, MD, director of pain management, Scripps Center for Integrative Medicine, La Jolla, California, and assistant clinical professor, University of California, San Diego.

Dr Bonakdar said he hopes his group will first develop a "white paper" with perhaps the "top 4 or 5 things that are essential for doctors who are seeing patients with pain to consider."

He elaborated on some of these "essentials" during an address to delegates at the American Academy of Pain Management (AAPM) 2016 Annual Meeting here. Dr Bonakdar is past president of AIPM and remains on its board of directors.

Inflammation Influence

He told his audience how nutrition can affect pain through many mechanisms. "Diet can influence inflammation, shift the microbiome, modulate the immune system, improve joint function, eliminate pain triggers, and reduce deficiencies."

Dr Bonakdar talked about the "state of the plate," which he said is "pretty dismal." Over 60% of foods consumed are highly processed, and the Western diet lacks fresh fruits and vegetables and fiber, he said.

A poor diet produces signs of inflammation, such as C-reactive protein (CRP), noted Dr Bonakdar. Elevated CRP levels can increase the risk for low back pain, for example, and there's a direct dose response, he said. "The higher the CRP, the more intense the pain is, and the more it can interfere with activities of daily living."

The Western diet also shifts the body's microbiome structure, which can affect digestion, Dr Bonakdar said. Over time, he added, this can have a significant effect on diversity of flora.

This lack of diversity is directly linked to many pain states, including chronic pelvic pain and irritable bowel syndrome, he said.

Consuming highly processed foods can also affect mast cells, which become "hyper-excitable," again causing pain, said Dr Bonakdar. He noted several disorders that are connected to mast cell–mediated mechanisms of nociception, including migraine, fibromyalgia, and neuropathic pain.

"If we are not feeding our cells appropriately, or we are feeding our cells toxic products or inflammatory products, the end result is going to be inflammation and pain."

Clinicians, he told Medscape Medical News after his presentation, don't often consider the effect of pain on cells. "Pain can in subtle ways affect the cell in very dramatic ways, but we don't often appreciate that or recognize it, or treat it because we are trying to get the headache better."

Addressing a question from a delegate about the inflammatory nature of grains, Dr Bonakdar said that "excess grains can be inflammatory, especially if there are issues with celiac or sensitivity." He added that he may suggest selectively removing grains from a patient's diet.

Many patients consume grains in a "quick hit" highly processed food. "This product doesn't have nutrients, anyway; there is nothing there except colorful packaging."

Magnesium is an important example of the pain-related impact of nutrients. About 70% of the population has a magnesium deficiency, and about 20% of the population "are not even getting half of the daily requirement," said Dr Bonakdar. Deficiency is defined as a serum level of less than 0.75 mmol/L.

There's a "very strong" association between lack of magnesium and migraine, said Dr Bonakdar. "The odds of migraine go up by 35-fold if you have a magnesium deficiency."

For patients with a magnesium deficiency, he recommends over-the-counter chelated formulations of magnesium, which are more bioavailable than magnesium oxide or magnesium sulfate. He typically starts patients on 200 mg of the supplement per day, titrating it up to 500 mg per day. He tells patients to take it at bedtime, when bloating side effects may be less noticeable. In addition to positive changes in muscles, patients have reported benefits on mood.

Patients can also get magnesium in their daily diet. Foods high in this nutrient include spinach, chard, pumpkin seeds, almonds, black beans, avocado, figs, and bananas.

Asked whether he checks a patient's serum magnesium levels, Dr Bonakdar said there is "no real standard" of how to do this. He takes a dietary history, and patient responses typically "tell me I'm on the right track" by treating them.

Another deficiency — in vitamin D — could also be important in the field of pain management. At least 70% to 80% of pain patients have a vitamin D deficiency, which can make nerves "hypersensitive," he said. In those with "ultra-low" vitamin D levels (serum 25-hydroxyvitamin D < 20 nmol/L), Dr Bonakdar recommends high-dose vitamin D in liquid form.

Dr Bonakdar also discussed the relationship between obesity and pain. One study — an analysis of more than a million Americans answering health survey questions — showed a direct dose-response curve between obesity and pain, especially as people age, he said.

Just as diet can increase pain, so too can it decrease pain.

Evidence indicates that a low-glycemic-index diet (based on how foods affect blood glucose), which is high in polyphenols, fiber, fruits, vegetables, healthy fats, and "good" sources of protein, has a positive impact on pain. Such a diet benefits the microbiome and increases bacterial diversity.

"So it pretty much reverses the trends we see with the Western industrialized American diet," said Dr. Bonakdar.

He also talked about the importance of "mindful" eating. "How much you're putting on your plate, how you're preparing that food, and how quickly you're eating it, all informs the occurrence of inflammation," even if the food is relatively healthy, he said.

There are some herbs and spices — for example, curcumin, a constituent of turmeric — that reduce pain and inflammation. Studies support this benefit of curcumin in patients with osteoarthritis and rheumatoid arthritis, said Dr Bonakdar.

Omega-3 fatty acid is another important nutrient when it comes to pain prevention — and it may also help in cognitive functioning, said Dr Bonakdar.

And some evidence links coenzyme Q10 to pain reduction. A study in adolescents with migraine and a deficiency in this natural antioxidant who took it in supplement form had reduced headache frequency.

Diet and Exercise

Combining an anti-inflammatory diet with exercise might boost the impact on pain even more. An 18-month study in patients with osteoarthritis who had weight issues — the IDEA trial — found that "diet was helpful, exercise was helpful, but the combination was the most helpful," said Dr Bonakdar.

"Even reducing weight by about 5% can have significant impact on pain and function."

There is more evidence from another study of 130 female patients with rheumatoid arthritis in a relatively poor area of Glasgow, Scotland. The analysis showed that patients who followed a healthy Mediterranean-like diet had significantly reduced pain at 3 and 6 months.

"At the end of the day, this is powerful medicine for pain management, and not just in rheumatoid arthritis," said Dr Bonakdar. "We now have clinical trials that show that diet in various forms — nutritional interventions, nutritional supplement interventions, combinations with nutrition and exercise — can be helpful in reducing pain from A to Z."

Asked to comment, Nancy Cotter, MD, who serves as physician lead for integrative health at the Veterans Administration in New Jersey, said there's plenty of evidence that nutrition is helpful for pain management at "multiple levels," including musculoskeletal and neurogenic pain.

"However, that awareness really hasn't permeated the consciousness of the general medical population, or the patient population" said Dr Cotter. "When we think of pain, we think of pills. That's been it."

American Academy of Pain Management (AAPM) 2016 Annual Meeting. Presented September 23, 2016.

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