Research is providing compelling evidence for Hippocrates’ oft quoted “Let food be thy medicine.” Despite this, most graduating physicians receive only a few hours of instruction about nutrition and coaching to help patients change their eating habits. Appropriate nutritional interventions may be one of the most useful tools doctors have to improve overall health outcomes in their patients and specifically reduce inflammation. Whether doctors choose to do this themselves or collaborate with other professionals trained in nutritional coaching, the benefits of attending to nutritional status can enhance outcomes of other therapies.
Key points
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Macronutrients such as proteins, carbohydrates, and fats provide the calories in food. Micronutrients such as vitamins, minerals, flavonoids, and other antioxidants are also essential for health.
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Heavily processed foods are high in calories and poor in micronutrients, leading to calorie excess and micronutrient deficiency in many Americans.
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An antiinflammatory diet can reduce the prevalance of many of the chronic diseases that are associated with pain: diabetes, cardiovascular disease, and obesity.
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Research into nutrients does not mirror drug research randomized controlled trials (RCTs) because nutrients, which bodies are programmed to use, work more slowly and physiologically than do drugs, which are “new-to-nature” molecules that often have dramatic effects and side effects.
Introduction
There is growing literature documenting the effects that lifestyle choices have on overall health outcomes by changing host susceptibility and the propensity to heal. The European Prospective Investigation Into Cancer and Nutrition (EPIC), Potsdam study, evaluated the effects of 4 lifestyle factors on health (never smoking; body mass index [BMI], calculated as the weight in kilograms divided by height in meters squared, less than 30; physical activity for at least 3.5 hours a week, and eating a healthy diet with vegetables, fruits, whole-grain bread, and low quantities of meat). The study revealed benefits for these 4 lifestyle factors that no drugs or procedures can remotely approximate. A total of 23,000 participants were followed up for 7.8 years. Participants with all 4 factors at baseline, when compared with those without a healthy factor, had a 78% lower risk of developing a chronic disease: specifically 93% reduced risk of diabetes, 81% reduction in myocardial infarction, 50% less chance of strokes, and 36% reduction in cancer. The common denominator of all these chronic conditions is inflammation: all the 4 factors studied reduce body-wide inflammation, which in turn can influence the course of chronic diseases. Each of these chronic diseases can affect pain, but the reduction of inflammation itself can affect the experience of pain.
A diet of processed foods tends to be high in calories with an abundance of unhealthy fat, refined carbohydrates, salt, and chemicals such as pesticides, stabilizers, antibiotics, and preservatives. Almost 80% of processed foods contain added sugar. Such a diet is poor in fiber, micronutrients, and antioxidants and is proinflammatory. Pain-specific studies are lacking in this area, but a month of following this practice (either for the practitioner or their patients) will convince most practitioners that “you are what you eat.” There are studies looking at the influence of diet on inflammatory markers showing that diets high in fiber, healthy oils, fruits, and vegetables and low in sugars, starchy carbohydrates, and unhealthy oils can reduce inflammation and disease.
The United States is faced with an obesity epidemic, and it is estimated that 1 in 3 Americans will become diabetic in their lifetime and that the figure increases to 1 in 2 for those of Latin American descent, African Americans, and American Indians. At present, in the preteen population, there is an increasing prevalence of obesity, diabetes and coronary artery disease and the attendant complications of other chronic diseases and pain syndromes.
Introduction
There is growing literature documenting the effects that lifestyle choices have on overall health outcomes by changing host susceptibility and the propensity to heal. The European Prospective Investigation Into Cancer and Nutrition (EPIC), Potsdam study, evaluated the effects of 4 lifestyle factors on health (never smoking; body mass index [BMI], calculated as the weight in kilograms divided by height in meters squared, less than 30; physical activity for at least 3.5 hours a week, and eating a healthy diet with vegetables, fruits, whole-grain bread, and low quantities of meat). The study revealed benefits for these 4 lifestyle factors that no drugs or procedures can remotely approximate. A total of 23,000 participants were followed up for 7.8 years. Participants with all 4 factors at baseline, when compared with those without a healthy factor, had a 78% lower risk of developing a chronic disease: specifically 93% reduced risk of diabetes, 81% reduction in myocardial infarction, 50% less chance of strokes, and 36% reduction in cancer. The common denominator of all these chronic conditions is inflammation: all the 4 factors studied reduce body-wide inflammation, which in turn can influence the course of chronic diseases. Each of these chronic diseases can affect pain, but the reduction of inflammation itself can affect the experience of pain.
A diet of processed foods tends to be high in calories with an abundance of unhealthy fat, refined carbohydrates, salt, and chemicals such as pesticides, stabilizers, antibiotics, and preservatives. Almost 80% of processed foods contain added sugar. Such a diet is poor in fiber, micronutrients, and antioxidants and is proinflammatory. Pain-specific studies are lacking in this area, but a month of following this practice (either for the practitioner or their patients) will convince most practitioners that “you are what you eat.” There are studies looking at the influence of diet on inflammatory markers showing that diets high in fiber, healthy oils, fruits, and vegetables and low in sugars, starchy carbohydrates, and unhealthy oils can reduce inflammation and disease.
The United States is faced with an obesity epidemic, and it is estimated that 1 in 3 Americans will become diabetic in their lifetime and that the figure increases to 1 in 2 for those of Latin American descent, African Americans, and American Indians. At present, in the preteen population, there is an increasing prevalence of obesity, diabetes and coronary artery disease and the attendant complications of other chronic diseases and pain syndromes.
Patient evaluation
We persist, as a nation, to subsidize grains instead of fruits and vegetables and have made fast foods and processed foods cheap, whereas fresh foods are unaffordable for much of the nation. There are food deserts in the United States where people cannot find fresh produce in their local stores. There are movements to reverse these trends, such as The Family Dinner Project, Slow Food, and Food Inc. Against the vigorous lobbying of food industries, a host of governmental and nongovernmental organizations are trying to improve school lunches and reduce the high-sugar, high-fat, empty calorie junk foods available in schools.
Taking a detailed dietary history must be done carefully to maximize patients’ openness about eating habits that may be causing embarrassment or guilt, especially if patients are poor, have been overweight, or had eating disorders. People can be simultaneously obese and malnourished. Many people do not know what real food is: things that come from a farm are food; things that come from a factory are usually not food anymore. This conversation can lead to a worthwhile discussion about how to seek out health-promoting foods.
It can be easiest to go through an example of the patient’s meal cycle: breakfast, lunch, dinner, and snacks. (For example, for breakfast, I ask specific details such as specifically what types of starches, cereal, and bread they eat; how much and what type of sweetener they use in their beverage; and whether they use cream or chemical-laden creamer.) Other important parameters are numbers of vegetables (in handfuls) and fruits, amounts of sugar or artificially sweetened beverages, amount of other sugars in the diet such as candy or pastries, and an idea of the relative amounts of processed foods versus homemade “from-scratch” foods.
People’s tastes become desensitized to sweet if they over ingest sweets. Very often, removing sweets from their diet for a week allows their palates to reregulate and they will use less added sweeteners of all kinds. The same holds true for salt.
Macronutrients and micronutrients
Macronutrients include proteins, simple and complex carbohydrates, and fats. These macronutrients provide the calories in food. Micronutrients are vitamins, minerals, enzymes, and antioxidants that are abundant in unprocessed fruits, vegetables, beans, legumes, nuts, seeds, and whole grains. Americans overconsume animal sources of protein and neglect the vegetable sources. The result is an overconsumption of unhealthy fats and reduction of the nutrient-replete plant sources of food. Americans are also heavy consumers of grains and their processed derivative foods.
It has been estimated that junk food makes up one-third of the average American diet.
Americans each eat an average of 68 kg of sugar and 68 kg of refined flour each year. These are high-glycemic foods that spike blood sugar quickly, usually resulting in a reactive drop in blood sugar that then precipitates food cravings, irritability, and increased inflammation. Chronic inflammation is associated with medical and psychiatric disorders, including cardiovascular diseases, metabolic syndrome, cancer, autoimmune diseases, schizophrenia, and depression, all of which adversely affect health and life expectancy and can exacerbate pain. A processed foods diet also promotes low pH, which in turn reduces the activity of essential physiologic enzyme reactions in the body (the optimal enzyme function pH is 6.5–7.5). Refined foods, sugar, meat, and dairy lower pH. Green vegetables, lentils, and most fruits raise the pH.
Eat, Drink, and be Healthy by Willett, MD, of Harvard is an excellent resource for practitioners and patients, outlining the evidence base of the health-promoting effects of a proper diet. Willett provides an alternative food pyramid to that of the United States Department of Agriculture. At its base are whole grains and plant oils, followed at the next tier by unlimited vegetables and 2 to 3 fruits per day. Nuts and legumes are the next most abundant food group followed by fish, poultry, and eggs, with dairy or calcium supplementation above that. At the very top, with the advice to use sparingly, are red meat, butter, and white food—white bread, pasta, potatoes, and rice along with soda and sweets.
Moderate use of coffee, tea, wine, and dark chocolate is sanctioned under the antioxidant banner. Awareness of the sources and quality of the products is essential, because all the above-mentioned foods tend to be produced with heavy pesticide use and can be chemically altered under certain circumstances. The Environmental Working Group is a watchdog group that compiles lists of contaminants and sources of least and most contaminated foods and makes these available to the public.
Merely understanding and explaining glycemic index (GI) and glycemic load to patients goes a long way to convincing them that they should pay attention to recommendations. GI refers to the rate of rise of the blood sugar after eating a certain food measured against the standard of a glucose load, which scores 100. A high-glycemic food is one with GI greater than 55. Low-GI foods produce only small fluctuations in blood glucose (BS) and insulin levels. Large fluctuations in BS begin the path to insulin resistance and the increase in inflammation that is now recognized as a factor in the development of most known chronic degenerative diseases. The glycemic load is (GI × the amount of carbohydrate) divided by 100 and takes into account the amount of carbohydrate intake as well as GI.
Supplementation
Drugs and Nutrients: Relative Safety
The safety profiles of nutritional supplements continue to be monitored and evaluated. There is the potential for adverse effects, interactions with drugs, and interactions between supplements. However, the statistics speak for themselves when comparing adverse effects from supplements with the adverse effects from commonly used medications and frequently performed procedures. A review of the Institute of Medicine reports To Err is Human and Shorter Lives Poorer Health and the works of Starfield, James, and Volkow and colleagues point out the significant morbidity and mortality from conventional medicines. In contrast, the National Poison Data System, which tracks deaths from drugs and supplements, reported no deaths due to multiple vitamins, A, B, C, D, and E, or any other vitamin, and no deaths attributable to amino acid or other dietary supplements in their 2010 report.
In family medicine, orthopedic, pain, rheumatology, sports, and physical medicine practices, there are many commonly used, nonlifesaving drugs that are associated with significant morbidity and mortality. Nonsteroidal antiinflammatories have been estimated to kill more than 16,500 patients per year within the diagnostic categories of osteoarthritis (OA) and rheumatoid arthritis alone. In addition, they may contribute to nutritional deficiencies from intestinal malabsorption and disruption of the microbiome: the masses of microorganisms that inhabit the body and outnumber the individual’s human cells in numbers of cells by 10:1. The balance of microorganisms can determine health or disease by affecting the absorption of nutrients, causing or preventing excessive gut permeability, affecting the function of the immune system, and stimulating unhealthy fermentation within the gut and may be responsible for some forms of abdominal pain. (The National Institutes of Health [NIH] have a consortium devoted to the study of the microbiome called the Human Microbiome Project. A PubMed search on “human microbiome” displayed 13,662 articles dating back to the 1950s with 12,565 published in the past 10 years.) The microbiome is also adversely affected by processed foods and many other drugs commonly used in physical medicine and rheumatology practices such as proton pump inhibitors (PPIs), antibiotics, steroids, and hormones. PPIs now carry a warning from the US Food and Drug Administration saying they are risks in the development of osteoporosis, Clostridium difficile infection, food poisoning, nutritional deficiencies of vitamin B 12 and protein, as well as potential life-threatening deficiency of magnesium. It has been known since the 1990s that gut bacterial imbalances can cause abnormal colonic fermentation and present as irritable bowel syndrome.
Specific supplements
It is impossible to review research on the merits of all the vitamins, minerals, antioxidants, and botanicals in this article. This article focuses on supplements that are readily available, affordable, and have been proved in practice to be highly efficacious in improving inflammation, pain, and healing.
Vitamin D
Studies repeatedly show that the population in the northern hemisphere is vitamin D deficient. More significant deficiencies are recorded in the chronic pain populations, and there can be improvement of pain with the mere supplementation of vitamin D. Grimaldi and colleagues have also shown that vitamin D improves muscle strength in men and women. The extensive study of vitamin D is impressing upon us that it is more of a hormone than a vitamin and is necessary for every system and cell type that has so far been studied. Deficiencies are associated with inflammation and susceptibility to illness, and sufficient levels are necessary for a healthy immune system.
In some patients, it is difficult to achieve optimal levels despite usual levels of supplementation, and therefore being guided by serum levels of 25-hydroxyvitamin D is helpful. It is known that deficiencies are more common in the elderly, the obese, and in those with more skin pigment. It is generally regarded as safe for people to take 2000 IU/d orally and the no adverse effect level, an international standard, has been set at 4000 IU daily.
Omega-3 Oils
Omega-3 and omega-6 polyunsaturated fatty acids (PUFAs) are essential nutrients that must be obtained from the diet. The North American diet is generally too high in omega-6 PUFAs and deficient in omega-3 PUFAs. Linoleic acid is the predominant omega-6 PUFA that promotes inflammation. The omega-3 PUFAs are alpha-linolenic acid, which comes from plants such as flax, and docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), which come from fish, organic free-range eggs, and grass-fed beef. Omega-3 PUFAs promote antiinflammatory pathways and are being investigated for their effects on headache. An RCT was conducted in which 56 of 67 patients completed a dietary intervention increasing n-3 and reducing n-6 fatty acids resulting in “reduced headache pain, altered antinociceptive lipid mediators, and improved quality of life in this population.” Lee and colleagues found nonsteroidal antiinflammatory drug (NSAID)-sparing effects with omega-3 oils in the treatment of rheumatoid arthritis, and Goldberg and Katz found an analgesic effect with supplementation for inflammatory joint pain. Maroon and Bost showed a 60% reduction in pain with the addition of 1200 mg of purified omega-3 fish oil in discogeneic pain. The doses used in many studies are 3000 to 4000 mg of combined EPA and DHA, which can usually be found in 6000 to 8000 mg of fish oil. (In most good-quality, microdistilled fish oil preparations there will be at least half the amount made up by the sum of the amount of DHA and EPA. For example, a 1000-mg capsule may have 230 mg of EPA and 270 mg of EPA for a total of 500 mg of the omega-3 PUFAs.)
Vitamin B 12
Vitamin B 12 is needed to make healthy blood cells and for optimal bone density. It is well known that neurologic dysfunction and chronic pain are consequences of deficiencies. Absorption from food sources depends on adequate stomach acid and drops with age. Vitamin B 12 is currently being studied to evaluate the correlation of tissue levels (likely the more significant level) with the serum level markers that can readily be tested. Mauro and colleagues found that vitamin B 12 injections in patients with pain who were not B 12 deficient resulted in reduced pain scores and analgesic use in both active treatment arms of a double-blind, placebo-controlled, crossover trial. In a British study, in 61- to 87-year-olds without cognitive impairment and with normal serum B 12 serum levels, brain size correlated with the B 12 level. The normal values in Europe and Japan have a higher range than that in the United States.
A dose of 1000 μg/d taken sublingually may produce improved symptoms of pain, insomnia, and fatigue. The sublingual route avoids the need for injections while still bypassing any impairment in gastrointestinal tract absorption.
Vitamin C
Vitamin C is a powerful antioxidant and is needed for the production of collagen, some hormones, and neurotransmitters. It is essential for tissue repair and adaptation to stress. Most animals can produce their own vitamin C, but humans cannot. The needs for vitamin C vary from day to day on the basis of the levels of stress, injury, or sickness. A moderate dose is 2000 mg/d. This dose is very modest when one considers that a 1.8-kg rat makes approximately 10 gm of vitamin C daily and can increase production 10-fold when stressed.
Magnesium
Magnesium is required for energy production and is used in more than 300 essential metabolic reactions. (The most commonly available magnesium sulfate, oxide, and citrate [usually in a liquid form] designed for the treatment of constipation and colonoscopy preparation are not well suited for absorption through the bowel wall. For this reason I recommend magnesium glycinate, malate, and citrate [as powder or pills] and recommend it be purchased from a supplements or health store.) Magnesium is essential for optimal bone density and collagen production, helps regulate serum glucose levels, controls the rate of nerve firing, and causes muscles to relax, making it the first choice for muscle cramps, spasms, myofascial tightness, and trigger points. Patients with Fibromyalgia are often magnesium deficient. Magnesium can improve blood pressure, palpitations, migraine frequency, and the cramping and pain of irritable bowel syndrome. Magnesium can improve sleep and is being studied for its role in neuropathic pain.
Magnesium deficiency is one of the most common deficiencies seen with the American diet. Magnesium is an intracellular mineral, and its serum levels, like those of calcium, are tightly regulated. Bones and muscles are reservoirs of magnesium, which may become depleted, even when the serum magnesium level is normal. The usefulness of red blood cell magnesium is not known because it is an anucleate cell and may also not reflect the sufficiency of intracellular stores.
Magnesium should be taken to bowel tolerance: one should take as much as tolerated on a daily basis to produce 1 to 2 easy-to-pass bowel movements. For some people this is 200 to 400 mg daily, and for others the doses is in thousands of milligrams. The result of overdose is diarrhea, which is remedied by lowering the daily dose of magnesium.
Turmeric and Ginger
Turmeric and ginger are related tubers, which have been extensively studied for their antiinflammatory properties. Terry and colleagues in their systematic review of ginger for pain concluded that ginger was a powerful antiinflammatory useful in treating pain. Ginger functions as an antiinflammatory by disrupting the cyclooxygenase 2 (COX-2) pathway at many points (ginger has 4 different ways to inhibit the enzyme COX-2, which promotes inflammation).
Curcumin is the active component of the turmeric tuber. Curcuma domestica extracts were found to have similar effects to ibuprofen for OA of the knee. Other studies have explored the antinflammatory properties of curcumin and its usefulness for postoperative pain. A review of hundreds of studies was published in Alternative and Complementary Therapies and concluded that “turmeric appears to outperform many pharmaceuticals in its effects against several chronic debilitating diseases, and does so with virtually no adverse side effects.”
Curcumin is best absorbed in the presence of oil and a small amount of black pepper. Heating also seems to activate the compound and make it more effective. (This is a personal observation and would be in keeping with the historical uses of turmeric as a spice used in cooking. The Ayurvedic preparation of Golden Milk involves heating the turmeric before use. Tablets of curcumin are convenient for travel and still are effective.)
Cinnamon does not have a known direct mechanism for affecting pain; however, it is being researched for its ability to reduce blood sugar levels and insulin resistance based on an insulinlike mechanism, which allows glucose to be absorbed into muscle cells bypassing the insulin receptor. This mechanism can indirectly affect pain by reducing inflammation and general health complications that accompany insulin resistance.
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