(Obesity and Chronic Pain: Similar physiology. Same aetiology?)
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Transcript of (Obesity and Chronic Pain: Similar physiology. Same aetiology?)
(Obesity and Chronic Pain:Similar physiology. Same aetiology?)
Prof Garry Egger MPH PhDSouthern Cross University
Chronic Pain & Lifestyle
…and if you get caught out - act sorry!
Main Points
• Obesity and chronic pain are linked biologically through a form of low-grade, systemic inflammation (‘metaflammation’), with glia playing a major role.
• Hence (much) chronic neuropathic (‘gliapathic’?) pain is lifestyle-related – leading to the conclusion that:
• Lifestyle change needs to be incorporated into any new ‘wholistic’ paradigm for chronic pain management.
Lucky Boyd
Obesity and Chronic Pain
Obesity Chronic Pain
• ~30 % of popn • ~20% of popn• Increasing (~2%pa) • Predicted increase (~4%pa)*• Lifestyle related • Lifestyle related (?)• Inflammatory link • Inflammatory base
Both a bigger problem in developed countriesBoth higher in lower SE groups
*Hohenberg KW, Lyons J, Daley TL. Chronic Pain. Decision Resources Report. March 2008.
Both have environmental aetiologies
35.3%35.3%38.9%38.9%
5.3%5.3%
20.4%20.4%
Underweight Normal weight Overweight Obese
Risk Factors: • low income • age • frequency of snacks • amount of exercise
of owners50%
25%
o%
(UK) Prevalence of Overweight and ObesityPr
eval
ence
Ref: Courcier EA, Mellor DJ, Yam PS. J. Small Animal Practice 2010; 3rd Feb
Ways of thinking about Obesity
The ‘linear’ approach:Weight = Energy in - Energy out X
A ‘systems’ approach:
BehaviourEnvironmentBiology
Influences
X Physiological adjustments
ModeratorsRef: Egger G, Swinburn B. Brit Med J. 1996; 20:227-231
Equilibrium fat stores
= Energy in-Energy out
Obesity: Always offender or often just accomplice?
Maximal adipocyte expandability (genetically determined)
Adipocyte (fat cell)
Lipid pool
Insulin sensitive
Pre-adipocyte
Blood Liver Muscle
Adipocyte expanded to maximal capacity
Macrophage accumulation
Inflammatory signaling
Expanded Lipid pool
Inflammation
Insulin resistant
Lipid‘spill-over’
The Fat ‘Spill-Over’ Hypothesis
Our inflammatory internal environment – ‘metaflammation’
Inflammation
ImmuneDefense
Resolution
Basal Homeostasis
Classical, Acute,Infectious Response
Im
mun
e Re
actio
n
Chronic Allostasis
Modern, Chronic.Non-infectious Response
Disease‘Dys-MetabOlism’
‘Meta-flammation’
Oxidative stress
InsulinResistance
Lifestyle/Environmental‘Inducer’
‘Agent’ (LDL)
MicrobialPathogen/‘Antigen’
Forms of Inflammation
Ref: Egger G, Dixon J. Obes Rev 2009 (in press)
Ref: Lamon BD, Hajar DP. Am J Pathol 2008;173(5):1253-1264
Inflammation (“metaflammation”) in chronic disease
Metaflammation
Chronic (Non-Communicable) Disease
Lifestyle Smoking Over-
Nutrition Starvation
Diet Stress/Depression
Inactivity Drug use
Over-exercise
Obesity
ExcessAlcohol
E N V I R O N M E N T
Pollution
+ Other Mechanisms(eg. oxidative stress, insulin resistance etc)
Ref: Egger G, Dixon J. Ob Rev 2009;10:237-249.
‘Inducers’ of Metaflammation
ANTI-Inflammatory ‘Inducers’ PRO-Inflammatory ‘Inducers’
A. LIFESTYLEExercise/Physical activity/fitnessIntensive lifestyle changeNutrition - alcohol (moderate) - capsicum - cocoa - dairy calcium - eggs - energy intake (reduced) - fish/fish oils - fibre - garlic - grapes/raisons - herbs/spices - lean game meats - low GI foods/Low N6:N3 - Mediterranean diet - fruits and vegetables
A. LIFESTYLEExercise - too little / too muchNutrition - alcohol (excessive) - excessive energy intake - fast foods/’western’ diet - fat - saturated/trans - high fat/high N6:N3 - fibre (low intake) - fructose/ glucose - high GI foods/diet/ load - meat (domesticated) - sugar sweetened drinks - starvationObesitySmokingSleep deprivationStress/Anxiety/Depression
- mono-unsaturated fats/olive oil - nuts - soy protein - tea/green tea - vinegarSmoking cessationWeight loss
B. ENVIRONMENTAir pollution (indoor/outdoor)Atmospheric CO2Perceived organisational injustice (low)Second hand smokeSE Status
UNADAPTED – POST-INDUSTRIAL REVOLUTION
ADAPTED
– PR
E-IN
DUSTRI
AL REV
OLUTI
ON
~1800 today-100,000
Egger G, Dixon J. Ob Rev (in press)
Affected Organs
• Endothelium(atherosclerosis)
•Lung(COPD)
• Brain(Alzheimer’s/Dementia)
• Joints(arthritis)
• Bowel (IBD)
• Neuron/Glia(neuropathic/‘gliapathic’? pain)
Range of ‘Metaflammatory’ Effects
Ref: Libby P. Nature, 2010
Modulation of the Neurovascular Unit by Pain
Ref: Willis CL, Davis TP. Current Pharmaceutical Design, 2008, 14, 1625-1643
Figure 1 | Glia–neuron interactions. Different types of glia interact with neurons and the surrounding blood vessels. Oligodendrocytes wrap myelin around axons to speed up neuronal transmission. Astrocytes extend processes that ensheath blood vessels and synapses. Microglia keep the brain under surveillance for damage or infection.
Ref: Allen NJ, Barres BA, Nature, 2009
Glia – More Than Just Brain Glue
Neu
ron
Neu
ron
Neu
ron
The Potential Impact of Glia on Central Pain Signaling
Ref: Fields D. ‘The Other Brain’, 2009
GliaGliaGliaGlia
The links between Chronic Pain and Lifestyle
Ref: Saastamoinen P et al., Pain, 2008
Lifestyle Factors and Chronic Pain – SE Factors
Ref: Kalameri et al., Eur J Pain, 2008
Number of Pain Sites by Lifestyle Behaviours –Norway
N=2926
Lifestyle, ‘Metaflammation’ and Chronic Pain
Ref: Shiri R et al. Eur Spine J, 2007;16:2043-2054
Metaflam- Endothelial Chronic Chronic Prevalencemation Dysfunction Disease Pain
Lifestyle processesInactivity + + + ? 50%Smoking + + + + 20%Passive smoking + + + ? -Poor sleep + + + + 33%Overweight/Obesity + + + + 60%Stress + ? ? + ~20%Nutrition Sat/trans fat intake + + + + - High GI load + + + ? -
+ = positive effect? = not sufficient evidence
obesity
diabetes
insulin resistance
CVD
cancer
aging
arthritis
gut healthimmune function
M E T A F L A M M A T I O N!!!
C H R O N I C P A I N???
Why nutrition & chronic pain?
”We literally eat ourselves into an inflamed and painful state and then seek out passive care from doctors to intervene on our behalf.”
Seaman DR. “The diet induced pro-inflammatory state: A cause of chronic pain and other degenerative diseases”. J Manip &Physio Ther 2002;25(3):168-179
Nutrition
obesity
diabetes
insulin resistance
CVD
cancer
aging
arthritis
gut healthimmune function
M E T A F L A M M A T I O N!!!
C H R O N I C P A I N???
Why exercise & chronic pain?
” Recent evidence suggests that the protective effect of exercise may to some extent be ascribed to an anti-inflammatory effect of regular exercise.”
Inflammation PL et al.. “Persistent low grade inflammation and regular exercise.” Front Biosc 2010 Jan
Exercise
Tissue inflammation
Neural sensitisation
Can we unknowingly contribute to the Can we unknowingly contribute to the persistence of pain ?persistence of pain ?
Inflammatory Inflammatory attitudesattitudes
Inflammatory Inflammatory actionsactions
Inflammatory Inflammatory relationshipsrelationships
Inflammatory Inflammatory eatingeating
Inflammatory Inflammatory environmentenvironment• toxinstoxins• smokingsmoking• medicationmedication
• stressstress• angeranger• bitternessbitterness
• excess starchy excess starchy carbohydrate carbohydrate
• over doingover doing• under doingunder doing• poor sleeppoor sleep
Models in Pain Management
Traditional (dualistic) Model Emerging (Holistic) Model
• Medical or psychological focus • + Social and environmental focus• More clinician centred • More patient centred• Limited benefits for limited time • Significant, long term benefits• Individual treatment approach • individual + group treatment • Patient as recipient of treatment • Patient as partner in treatment• Potential dependency/ complications • Limited dependency/complications• Distracts recipient from active • Involves recipient in active self-
management management• “Siloed” health system approach • Integrated health system approach• Neural plasticity disregarded • Neural plasticity vital for treatment• Ongoing/discontinued biomedical • ‘Tapered’ biomedical treatment
treatment• Individual health perspective only • Population health perspective• Little or no attention to lifestyle • Significant attention given to lifestyle
change
The Australian Lifestyle Medicine Association (ALMA)
www.ALMA.net.au
Thank you
Chronic Pain and Lifestyle MedicineGarry Egger Southern Cross University, Lismore and Centre for Health Promotion and Research, Sydney
Chronic pain is an increasingly common phenomenon in modern societies. It’s not coincidental that this corresponds to an increase in several other lifestyle-related chronic diseases or risk factors (type 2 diabetes, depression, cancers etc), which have recently been shown to have a common physiological aetiology in low grade, systemic, inflammation (‘metaflammation’). Coupled with findings of increased plasticity in the brain, it is not outrageous to speculate that metaflammation may extend to both central and peripheral glial connections associated with pain perception, thus linking lifestyle-related ‘inducers’ to non-specific and unresolvable chronic pain. Even without such a biological basis, there is evidence to suggest that lifestyle change may have a positive effect as part of a systems-theory approach to chronic pain management. The potential benefits of a ‘Lifestyle Medicine’ approach to chronic pain management are considered in this regard.