11. Nutrition and Pain · • Chronic pain changes how we perceive food too –Fat less satiating...

Eating for Whole HealthDay 2 Afternoon

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• Nutrition and Pain

• The Whole Health Visit: Creating a Personal Health Plan

• Nutrition and Whole Health: Transforming the System

11. Nutrition and Pain

Eating for Whole Health

Nutrition and Pain Objectives

• Describe the relationship between nutrition and inflammation

• Discuss the relationship between inflammation and pain

• Name two dietary interventions that can be used for pain management


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Anna has Arthritis

• 47 year old Army Gulf War Veteran

• Osteoarthritis (OA) – knees, hands

• Given oxycodone

–Hates how it makes her feel

– Struggles with fatigue

• Offered injections

• Comorbidities – HTN, obesity, GERD

• Art professor‐ requires standing

• Would like to know if there are things she can add to her diet for natural pain management

OA: Not‐so‐fun Facts

• OA: most common cause of disability among service members medically separated from active duty*

• By 2030, ¼ of Americans will have osteoarthritis **

• Complex – not just ‘wear and tear’– Physiological pathways go awry– Chondrocytes: irregular collagen network– Osteoblasts: Microfracture – callus – microfracture– Interleukins, cytokines in muscles, tendons, ligaments

• Options can seem limited– Pills– Procedures (surgery, injections)– PT

*Cross JD, et al . Battlefield orthopaedic injuries cause the majority of long-term disabilities. J Am Acad Orthop Surg. 2011;19(suppl 1):S1–S7. **Osteoarthritis, in Rakel D (ed) Integrative Med 3rd ed, Philadelphia: Elsevier, 2012

Photo: Rakel, Integrative Med, 3rd ed

Around the Circle with Anna

Where should we start?


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Nutrition and Pain

• Nutritional therapy common in systems of healing (Ayurveda, TCM)

• Less incentive to study food

• Connection of diet and pain is multifactorial

• As early as 1958, British Cohort Study showed effects

– Correlation of chronic widespread pain and poorest eating*

• Chronic pain changes how we perceive food too

– Fat less satiating

– Reduced satiety = more overeating

– Ventral striatum (rewards system) and prefrontal cortex changes – lower food pleasure

– Regardless of obesity

*Vandenkerkhof EG et al, Pain Res Manag, 2011;16(2):87-92. **Geha P et al, Pain 2014;155(4):712-22.

Mainstream Recognition

Cytokines (inflammatory signals)

• Responsible for multiple aspects of inflammatory process

–pain initiation and persistence

• Direct activation of nociceptive (pain pathway) neurons

–Contribute to nerve‐injury/inflammation‐induced central sensitization

• Can influence development of hyperalgesia/allodynia

• Can be directly affected by food


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Inflammatory Mediators as Pain Mediators

Commonly Measured in Research

• Prostaglandins– Sensitize peripheral nociceptors

• Leukotrienes: – Increase vascular permeability

• TNF-α– Activates NF-κΒ (proinflammatory signaling pathway) & apoptosis

– evokes spontaneous sensory electrical activity

• NF-κB– Binds to DNA to increase transcription of proinflammatory

cytokines

– final common pathway for activation of cytokine production

Inflammatory Mediators & Structural Modulation

• TNF-α: Elevated in RA and OA joints

• IL6: Increases osteoclast activity/bone studies

• PGE2: High levels impede collagen synthesis

• Nitric oxide: Regulator of response inflammatory mediator in joints

• Mechanical stress may precipitate release/activity of inflammatory mediators

Osteoarthritis: The Rotterdam Study

• N= 5600 people > 55; women> men• X-rays of the knee, hip, hand scored using the Kellgren score for

OA at T=0, T= 6.6, T=10 years • Intimal thickness (IMT) and carotid plaque

measured T=0

• IMT showed independent association with the prevalence of knee osteoarthritis

• Carotid plaque with distal interphalangeal (DIP) OA and metacarpophalangeal (MCP) osteoarthritis

• Take home: OA may be a reflection of overall inflammation

Hoeven TA et al Ann Rheum Dis 2013 72(5):646-51


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Nutrition, OA & Weight

-Christensen R et al., Osteoarthritis Cartilage, 2005;13:20-7.

-Messier SP et al. Osteoarthritis Cartilage, 2010;19:272-80.

totalbodycoach.tumblr.com

• Lose excess weight = improve function!

–10 lb = 28% function – N=80, intervention a low energy diet, weeklydietary sessions

– NNT to improve WOMAC scores by >50% was 3.4

–Pathological changes• Decreased joint compression

• Altered hamstring firing

– IDEA trial (Messier) • Both diet and exercise contribute to weight loss and pain reduction

• Diet changes bigger contributor

-Messier JAMA. 2013;310(12):1263-1273

Nutrition Tools

• Anti‐Inflammatory Diet

• Elimination Diet

–will discuss during headache module

• Microbiome

Balanceforlifellc.com

Anti‐Inflammatory Diet – Highlights

• What affects inflammation

– The fats we eat

• Omega‐3’s and 6’s/ratio

– Antioxidants

– Glycemic index

– Microbiome

• Mediterranean Diets

– anti‐inflammatory

• 14 key steps– Not imperative to do all at once

The Anti-inflammatory Food Pyramid.

Drweil.com


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14 Ways to Eat Toward an AID

1. Keep non‐fish animal fats intake low

2. Eat more fish

3. Limit omega‐6 fats

4. Eat more omega‐3’s

5. Keep vegetable and fruit intake high

6. Eat whole grains

7. Eat dietary fiber

8. Eat legumes

9. Eating nuts and seeds

10. Include anti‐inflammatory herbs and spices

11. Avoid charred foods

12. Pay attention to glycemic load

13. Avoid obesity

14. Ensure adequate magnesium

Anti‐inflammatory Diet

• Be fat smart – Limit saturated

– Avoid trans fats

– Emphasize omega-3

• Eat 5-9 servings of fruits and vegetables/day

• Use antioxidant herbs and spices

• Eat 25+ grams of fiber each day

• Optimize glucose metabolism

Fruits and Veggies

• GOAL: 5‐9 servings daily–ensures 25 grams fiber –Assists in maintaining microbiome

• Fiber is fab!–binds toxins and cholesterol – stool exit time / CRP

• Studies show– intake of fruits and vegetables inflammation CVD

• Phytochemicals inflammation


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Meal Composition Matters

• Low insulin diet may decrease plasma CRPMcCarty MF Low-insulin-response diets may decrease plasma C-reactive protein by influencing adipocyte function Medical Hypotheses 2005 64(2):385-7.

• High glycemic load correlates positively with plasma CRPLiu S. Manson JE. Buring JE. Stampfer MJ. Willett WC. Ridker PM. Relation between a diet with a high glycemic load and plasma concentrations of high-sensitivity C-reactive protein in middle-aged women. American Journal of Clinical Nutrition 2002 75(3):492-8

Minding The Microbiome In Pain

• Did you know… –We are 10x more non‐human than human cells

• We want to have our friends on board!

• Prebiotics and probiotics –Can modify the microbiome

–Maintain a healthy state, respectively

How do Food, the Microbiome and Pain Interact?

• Diet is a driving force in gut microbiome diversity and composition

• fiber (supports microbiome) = likelihood of OA

• Specific microbes identified in relation to specific metabolic host interaction

Lozupone CA, Stombaugh J, Gordon J, et al . Diversity, stability and resilience of the human microbiota. Nature 2012;489:220–30.

Hildebrandt MA, Hoffmann C, Sherrill‐Mix SA, et al: High‐fat diet determines the composition of the murine gut microbiome independently of obesity. Gastroenterology 2009;137:1716–24.


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Studies on Anti‐inflammatory Spices

Shobana S. Naidu KA. Antioxidant activity of selected Indian spices. Prostaglandins Leukot Essent Fatty Acids. 2000;62:107‐110.

Cloves > Cinnamon > Ginger > Garlic

Popovic M, et al. Effect of parsley extracts on some biochemical parameters of oxidative stress in mice treated with CCl(4). PhytotherRes. 2007;21:717‐723

Yadav AS, Bhatnagar D. Modulatory effect of spice extracts on iron‐induced lipid peroxidation in rat liver. Biofactors. 2007;29(2‐3):147‐157.

Joe B, Vijaykumar M, Lokesh BR. Biological properties of curcumin‐cellular and molecular mechanisms of action. Crit Rev Food Sci Nutr. 2004;44:97‐111.

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Why Fat Is Important

Resolvins

OnionsGinger

TurmericRosemaryFeverfewBoswellia


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A Word on Dietary Supplements

Dietary Supplements for Pain: A Clinician’s Guide

–Summarizes research & prescribing tips

–Formulary

• fish oil, vitamin D, magnesium

–Foods• ginger, turmeric

–Table for others • name recognition

Photo b Adam Rindfleisch

PP219

What Did Anna Do?

• Discussed needs with provider• Participated in creating PHP

• focus on food, drink, and movement

• RD referral

• plant based, nutrient & fiber, glycemic eating plan

• Focus: inflammation and promoting weight loss

• Attended Healthy Teaching Kitchen class

• Results (thus far) over 9 months

• 15% weight

• Preps own nutrient dense meals

• remains active & manages breakthrough pain with NSAID <2 x/month

• Thinking about taking “Power of the Mind” Class to help with her pain

Meet Mike

• 33 year old OIF Veteran

• Hx migraines & tension headaches

– 1 or 2 each week

• Multiple meds tried

– HATES side effects

• Wonders about other approaches

• Acupuncture helped to reduce by 50%

• Poor diet and steady weight gain

• Limited physical activity

• Sees psychiatrist and counselor for PTSD

Blog.handmadebyheroes.com


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• Migraine & tension headaches• 2nd & 3rd most common condition

– 11% MHA

– 98% have at least one

• Headaches are systemic • Hyper vigilance

• Nervous system hypersensitivity

• Multiple contributing factors

• Not just about ‘triggers’

• Genetics

• Comorbidities – mood, sleep, and pain disorders, allergies, epilepsy

• Lifestyle, diet, stress, neck pain

• Often need multiple interventions

– One is rarely enough

Headaches: The Facts

Horsesmouth.typepad.com

Headache Threshold

Comorbidities

Stress

Fatigue

Body Chemistry

Genetics Migraine

When it all adds up above a certain

threshold, the body moves into a

headache state.

How do we decrease the chance of

overfilling?

Comorbidities

Stress

Fatigue

Body Chemistry

GeneticsMigraineMigraine


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Quick Tips

Food and Drinks for Headaches: • Don’t skip meals

• Reactive hypoglycemia

• Eat at regular times

• Achieve optimal weight –Obesity migraines

• Be mindful of caffeine intake and withdrawal

• Stay hydrated

• Consider an allergy‐elimination Diet

What did Mike do?

• Met with RD – Created plan to eat regular, balanced meals

– Increased Mg containing foods

• Began MgOxide from VA – 400 mg bid per provider’s suggestion

• Started allergy inflammation diet – Found sensitivity to wheat and soy

• Avoided x 3 months

• Retrial showed mild reaction (fatigue)

• Continued to receive acupuncture

• Breathing techniques for relaxation when migraines are active


page 128

Nutrient Mineral Deficiencies

page 128


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Maintz N, Novak N Am J Clin Nutr 2007;85:1185–96

How did Mike do?

• Avoided wheat and soy for 3 months; re-trial showed mild reaction to wheat (fatigue) and almost immediate reaction to soy

• Able to eat wheat about once per week, but may experience fatigue; now avoids soy completely

• Maintains his healthier diet with some deviations

• Headaches occur less than once per month


page 128

‐ The Bottom Line ‐

page 128• Food can have a profound effect on pain

• Modification of nutritional status, inflammatory profile, and the diversity of our microbiome can significantly impact pain

• Nutrition can be a safe, efficient and empowering component of a Whole Health oriented pain management program


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12. The Whole Health Visit:

Creating a Personal Health Plan


Objectives

• Identify how to create a Personal Health Plan by integrating information and discussion from review of the PHI

• Create a personal statement (“Elevator Speech”) about how the Whole Health Approach to care is beneficial

• Practice creating a Personal Health Plan (PHP) using the PHI in combination with the PHP template

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The Personal Health Plan is central to the WH System

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The Big Questions, Mission/Aspiration and Purpose

Synthesizing Information: The Whole Health Assessment

Whole Health Assessment: Patient Self Reflection Tools


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Practice of Whole Health

Whole Health Assessment tools:Clinician Expertise and Health Risk Assessment

HealtheLiving

Assessment

Framingham Risk

Assessment

Osteoporosis Risk

Assessment

Opioid Risk

Functional Status

Clinician Expertise and Data

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• Comprehensive History & Physical exam, Patient Interview

• Diagnostics (genomics, labs, tests)

• Other resources that could be incorporated if desired(tools from NCP)

Goal Setting : Shared Goals, SMART Goals


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Shared Goals

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Assess Readiness

page 128

On a scale from 1 to 10, how important is it for you to make a change in this area?

page 128

On a scale from 1 to 10, how confident are you that you can make some changes in this area?

Assess Readiness


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SMART Goals

S= Specific

M= Measureable

A= Action Oriented

R= Realistic

T= Time Sensitive

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EXAMPLEs

• Food and drink Goal : I would like to start eating more vegetables in my diet

• Made Smart: I will eat at least two servings of vegetables per day for 10 days starting tomorrow

Skills and Tools: Education, Skill Building, Resources and Support

PHI Can Lead to a PHP –Veteran Co‐Creates Next Steps

Personal Health Inventory (PHI) Personal Health Plan (PHP)

CM 53


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• Personal mission

• Shared Goals

• Self‐care

• Professional care

• Skill‐building/education

• Consults/referrals

• Timeline and follow‐up

Personal Health Plan Elements

The PHP Process is an ongoing process

Case study: Gary Johnson


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Gary’s Past Medical History Revisited

• Gary retired fourteen years ago (sold his book store)

• He was diagnosed with type 2 diabetes 12 years ago. His most recent HbA1c is 8.4 and he has early (stage 3a) kidney disease

• His blood pressure is 138/88, and he is not formally diagnosed with hypertension

• He has a history of mild‐moderate depression and PTSD

• His weight has increased over the last 4 years since his wife passed, and he currently weighs 220lbs (BMI 33.5)

Gary’s Potential Circle of Health

Gary’s Potential PHI


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Gary’s Areas of Self Care Rankings

Gary’s Reflections

ReflectionsNow that you have thought about what matters to you in all of these areas, what isyour vision of your best possible self? What would your life look like? What kindof activities would you be doing?

I want to be able to stay independent as long as possible. I think I need to eat a little better (limitingsweets and convenience foods) and try to get more active and stronger so I can stay in my own home. Iget lonely at times and would like to find a way to meet more people.

Are there any areas you would like to work on? Where might you start?

Food and drink- I need to work on my food choices and choose things that are better for my diabetes and blood pressure. Moving the body- I should work on increasing my strength and activity.

Creating Gary’s PHP Together

Strengths:

• Incredible resilience and “power of the mind” is demonstrated through his survival story of enduring trauma/capture/POW camp and yet went on to manage 5 businesses with his wife

•Relationships bring him joy and a sense of purpose

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Challenges:•Would like to make Better Food Choiceso Gary often eats too much due to his food insecurity issues and now is choosing more convenience foods with minimal nutritional value since his wife died. He recognizes that he should work on being more mindful with his eating.

•Has decreased Strength and Physical Activity

•Reports Loneliness/Lack of sense of community


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Creating Gary’s PHP Together

•Personal Health Plan for: Gary Johnson

•Date: 1/16/19

•MAP: Gary’s joy in life comes from connecting with other people and feeling useful.

•Gary’s goals:

1.Improve nutrition and limit foods that negatively impact my blood sugar along with my blood pressure (especially donuts, bagels and chips).

2.Increase physical activity to help with weight management and strengthening.

3.Work with social worker and psychologist to use counseling, natural medications and mind‐body strategies to manage PTSD and loneliness.

CM 53

What might be potential elements/goals for Gary’s self‐care?

My Plan for skill building and support:

Mindful Awareness:

• Keep a sleep journal• Try to notice if I am really hungry when I eat

• Pay attention to potential triggers for flashbacks

Areas of Self‐Care:

• Working your Body‐ Increase walking/hiking to 3 days per week with a goal of building to 30 minutes per session; Consider a chair yoga or tai chi class at the VA

• Food and Drink‐ See the dietitian. Stop drinking sugary beverages like cola and iced tea. Limit my intake to 1 caffeinated beverage per day. Attend one of the Healthy Teaching kitchen classes.

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Recharge‐ Review information on sleep hygiene. Continue taking melatonin. Keep seeing my counselor.

Family, Friends and Co‐Workers‐continue fishing with my best friend Mike. Reach out to my grandson with a phone call to reconnect. Go out to church or the senior center once a week.

Spirit and Soul‐ Consider a prayer group or Bible study group at your church to provide more social contact and help you feel more spiritually connected.

Power of the Mind‐ Continue seeing my psychologist and learn deep breathing exercises to help me deal with my flashbacks. Also consider learning about biofeedback.

Gary’s PHP

Professional Care: Conventional and Complementary

• Prevention‐ Up to date

• Testing‐ Keep up with Chol tests and HgbA1c as scheduled

• Medications and Supplements ‐ continue medications as prescribed. Okay to continue with dietary supplements of melatonin and glucosamine sulfate as discussed.

• Treatment‐ Start a BP log and check BP twice daily. See the nurse in clinic in 2 weeks for BP check.

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Referrals/Consults:

• Nutrition

• PT

• Psychologist

• Social Work

Community

• Church groups

• Volunteering

• YMCA

Resources

• Handouts on sleep hygiene

• BP Log sheets

• Patient Education Resource Center to learn about mindful awareness apps on the computer; learn about hospital support groups


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VA Physician incorporating the PHI/PHP into clinic visit

https://www.youtube.com/watch?v=Ac3I0OuUnoA

Sharing Your Experience

• Share a brief “elevator speech” or explanation of why you think this Whole Health approach is important

• Review any reflection tools the patient has brought with them (PHI or beginning of PHP) OR ask them the Big Questions

• Use this information as a springboard for your time together while also sharing your expertise as a clinician

• Identify the shared goal(s)

• Collaboratively create a SMART goal

• Connect patient to resources, training and skills to support them in reaching their goal

Working the PHI and PHP into your practice


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Telling Others About Whole Health:The Elevator Speech Exercise

• Draft out a 30‐second elevator speech using the form on CM Page 50

• Can use suggested elements or add your own

• Give your speech to a partner, and listen to your partner’s speech

• Offer constructive feedback• We will invite volunteers to share

with the large group

claybanksstudio.com

CM 50

pp20

Please bring out your completedPersonal Health Inventories (PHIs)

• This is a partner exercise

• Disclose only as much as is comfortable

• This is a partner exercise

• Disclose only as much as is comfortable

Food & DrinkNourishing and Fueling

Specific Health Issues

• Referrals• Diet & depression• Diet & sleep• Eliminating certain

foods• Probiotics

Prevention• A way to reduce

cancer risk• A step to

prevent heart disease

• An approach to blood glucose

Cooking Tips• Grocery shopping• Using kitchen

tools• Try a new recipe• Cooking classes

•

Food in Context• Cultural needs• Transportation• Finances• Peer support• Dietitians• Include whole

family• Setting the table

Nutrition ResourcesNutrition Resources(see list in manual)

• Cookbooks• Recipes• Websites• Nutrition classes• Community

programs

General Guidelines

• Follow a specific eating plan

• Macronutrients• Micronutrients• Phytonutrients • Meal timing &

frequency

Mindful Eating

management

Mindful Eating• Start a daily

practice• Number of chews• Pacing eating• Eating without

distractions• Observing

cravings• Stress

management

More Guidelines• Fruits, veggies,

nuts• Dessert

frequency• Hydration• Alcohol and

caffeine

CM. 47


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Steps in the Process – Try it!

• Choose a partner you didn’t previously know

• Introduce Whole Health

• Look at PHI

• Discuss the circle, pick an area of Food and Drink

• Generate a plan (SMART goal)

• Discuss referrals, team members skills, resources, follow up

• Take 8‐10 minutes each

CM 53

CM. 53

Sharing Your Experience

79


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Faculty Q&A Panel

From questions you submitted on note cards

STRETCH!

Faculty Q&A Panel

From questions you submitted on note cards


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13. Nutrition and Whole Health: Transforming the System


• Stand up and form two circles at the front of the room (one inner circle facing one outer circle). Bring paper and a writing utensil.

• The INNER CIRCLE will rotate to the right every 3 minutes (we will let you know when).

• With your “date”: Take turns discussing the prompts we provide.

• Feel free to write down ideas / suggestions from your partner.

• At the end of speed dating, return to your table and discuss what you’ve learned.

VA Speed Dating: Brainstorming Session

• Discuss an innovative approach to whole health/nutrition that you or your site has already implemented

• Total time: 3 minutes

Prompt #1


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• What is something you learned over the last two days that you can put into practice tomorrow?

• Are there any barriers to putting this into practice?


Prompt #2

• How do you see the future of whole health / nutrition at your site?


Prompt #3

• What are some personal changes that you can make to exemplify the whole health model?

• How will you make sure you can follow‐through with your health plan?


Prompt #4


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• What are some nutrition resources that you might use after this course to continue to expand your knowledge of integrative nutrition?


Prompt #5

LARGE GROUP DISCUSSION:

Whole Health Implementation

Closing Remarks And

Pulse Check: Day 2 Evaluations

THANK YOU!


Page 69‐70


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COURSE RESOURCES

Truly,youarewhatyoueat.Everythingthatgoesintoyourbodycanbecomepartofit.Goodnutritioncanhelpyoufeelbetterinallsortsofways,anditcanhelppreventfutureproblemsaswell.HerearethingstoexploreifyouwantFood&DrinktobepartofyourWholeHealthPlan.

CreateYourOwnFood&DrinkPlan.You are most likely to follow through with a plan for healthy eating if you take it slow and make one change at a time. Don’t get caught up in “good” and “bad” labels. It’s not just about how many calories – different sources of calories affect the body

differently. Consider your budget and what you have access to. Is there a something it would be good to add more of to your diet? To remove? Can you change just one habit related to Food & Drink that you don’t want to follow?

ZeroingIn–Food&Drink:Nourishing&Fueling

KeyPoints Figure out the way to eat that

works best for you as an individual. Buying and preparing food are

skills. What more can you learn? Eat a colorful diet with a lot of

natural foods, especially vegetables and fruits.

Really pay attention when you eat. Notice if you are hungry or not.

You can adjust what you eat to help you with your health problems.

Get support from dietitians.

Food&DrinkPlan

VA SKILLBUILDING COURSE FOR PATIENTSVA Skill Building Course for Patients



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11. Nutrition and Pain · • Chronic pain changes how we perceive food too –Fat less satiating...

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