Healthy Eating Quiz Is a Brief Diet Quality Tool • Higher HEQ = Regular Intake and Bigger Variety of Healthy Foods, Esp

Why, what and how of nutrition for people experiencing chronic pain • Q&A: Please type your questions into the Q&A section of the Zoom meeting control panel • Tweet Using #GlobalYear2020 and follow @IASPPAIN on Twitter. • Visit iasp-pain.org/GlobalYear for resources Why, what and how of nutrition for people experiencing chronic pain

Prof Clare Collins PhD, BSc, Dip Nutr&Diet, Dip Clin Epi, FDAA @ProfCCollins A/Prof Tracy Burrows PhD, B Nutr&Diet (Hons I), AdvAPD @DrTracyBurrows Dr Katherine Brain PhD, Nutr&Diet (Hons I), APD @Dr_KBrain Why is nutrition important for people experiencing chronic pain? Professor Clare Collins PhD, BSC, Dip Nutr&Diet, Dip Clin Epi, AdvAPD, FDAA Professor in Nutrition and Dietetics Director of Research, School of Health Sciences NHMRC Senior Research Fellow Faculty of Health and Medicine, Gladys M Brawn Senior Research Fellow The University of Newcastle @ProfCCollins Has a patient asked you whether they should follow these diets?

http://blog.move-15.com/wp-content/uploads/2014/08/raised-hands.jpg Has a patient asked you whether they should follow these diets? 5:2 diet Has a patient asked you whether they should follow these diets? 5:2 diet Ketogenic diet Has a patient asked you whether they should follow these diets? 5:2 diet Ketogenic diet The low FODMAP diet Has a patient asked you whether they should follow these diets? 5:2 diet Ketogenic diet The low FODMAP diet Probiotics to feed microbiome Has a patient asked you whether they should follow these diets? 5:2 diet Ketogenic diet The low FODMAP diet Probiotics to feed microbiome All of the above (raise 2 hands) Has a patient asked you whether they should follow these diets? 5:2 diet Ketogenic diet The low FODMAP diet Probiotics to feed microbiome All of the above (raise 2 hands) People are interested in nutrition …. but knowing who and what to believe …or what to eat, can be very confusing

https://3c1703fe8d.site.internapcdn.net/newman/gfx/news/hires/2017/americansare.jpg Nutrition matters for pain

 Pain affects what you choose to eat or drink  Pain reduces ability to plan ahead, shop for food, cook and feed yourself  Pain changes nutrient requirements  Nutrient intake may influence pain (omega-3 fats)  What you eat influences risk of chronic conditions (heart disease, diabetes, some cancers)

Pain Management Network. Pain: Lifestyle and nutrition. 2015; Available from: http://www.aci.health.nsw.gov.au/chronic- pain/for-everyone/pain-lifestyle-and-nutrition. Brain K, Burrows T, Rollo ME, Hayes C, Hodson FJ, Collins CE. Population Characteristics in a Tertiary Pain Service Cohort Experiencing Chronic Non-Cancer Pain: Weight Status, Comorbidities, and Patient Goals. Healthcare (Basel). 2017;5(2). Interactions between pain and nutrition Nutrition 101

• Food = macronutrients + micronutrients + water • Macronutrients; protein, fat, carbohydrate, alcohol, fibre • Fat – can be saturated, polyunsaturated or monounsaturated • Omega-3 fatty acids are specific polyunsaturated fats that cannot be made by the body • Micronutrients (vitamins, minerals, phytonutrients) • Some complimentary & alternative medicines (CAM) contain phytonutrients • Balanced diet provides all the nutrients needed to meet your requirements = “High diet quality” Omega-3 fats in chronic pain

• Fat quality influences synthesis of pro- versus anti-inflammatory cytokines • Omega-3 fats increase synthesis of anti- inflammatory cytokines • Increase omega-3s. Eat more oily fish (salmon, sardines), canola oil, linseed, flaxseed, walnuts • Fish oil supplements, aim for a product with EPA/DHA ratio >1.5 • Reduce polyunsaturated fats (sunflower and safflower oil) Nutrition requirements in chronic pain

• Diet quality tool or index measures nutrient adequacy and alignment with National Dietary Guidelines • Lower diet quality predicts morbidity and mortality • Higher diet quality moderately protective All-cause mortality risk  17-42% CVD mortality  18-53% CVD risk  14-28% Cancer mortality  13-30% All-cancer risk  7-35%

Wirt A &Collins CE. Public Health Nutrition 2009; 12(12), 2473 –92 Quality of life in Australian Longitudinal Study on Women’s Health by quintiles of Diet Quality Score SF36 component scores 1 2 3 4 5 (Scored 0-100) lowest highest 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

(1=poorest diet quality, 5= highest diet quality) (n~9700 mid-aged women)

Collins CE, Young AF, Hodge A. Journal of the American College of Nutrition, 2008 Feb;27(1):146-57. www.healthyeatingquiz.com.au

• Healthy Eating Quiz is a brief diet quality tool • Higher HEQ = regular intake and bigger variety of healthy foods, esp. vegetables and fruit Pain and malnutrition risk

• Patients with pain might eat less or eat less healthily during acute pain episodes • This increases risk for all types of malnutrition:- • Protein-energy malnutrition (wasting) • Excessive weight gain (obesity) • Weight gain (fat mass) with loss of muscle (sarcopenic obesity) Pain and malnutrition risk

• Decreased physical activity leads to loss of lean body (muscle) mass • Reduces resting and total energy expenditure • If inflammation and obesity co-exist there is additional disruption to muscle structure Malnutrition Screening Tools Malnutrition Screening Tool A score of 1= low risk A score of ≥2 needs follow-up Pain Management Network  https://www.aci.health.nsw.gov.au/chro nic-pain/chronic-pain Malnutrition Screening Tools

Potential Follow-up options  Refer those at risk to GP for potential chronic disease management (CDM) plan  http://www.health.gov.au/internet/main/publishing.nsf/

Content/mbsprimarycare-chronicdiseasemanagement  5 allied health visits per year  Accredited practicing dietitian and physiotherapist  Find an APD www.daa.asn.au  Review protein and nutrient intakes relative to requirements  Review food patterns and diet quality Pain and weight change

• ePPOC: 70% overweight or obese 2016 (Blanchard 2017) • 80% HIPS patients overweight or obese in 2014 (Brain 2017) • Pts with obese BMI (>30 kgm2) 2 x more likely to experience pain (Stone 2012) • Increased weight = increase inflammatory markers

Blanchard M et al. (2017) Electronic Persistent Pain Outcomes Collaboration Annual Data Report 2016. Australian Health Services Research Institute, University of Wollongong. Brain K et al. Healthcare. 2017;5(2). Stone AA et al. Obesity (Silver Spring). 2012;20(7):1491-5. Medication side-effects • Pain medications can have side-effects and a negative impact on nutritional status:- • Constipation, nausea, appetite changes, dry mouth, urinary retention, respiratory depression • 10% patients reported taking ≥ laxative medications in recent audit (Brain 2017) • These can be managed:- • Advice on boosting soluble (psyllium husk) and insoluble fibre (wheat bran) and fluid intake (water) • Refer to APD if intractable • DAA, Smart Eating, Constipation

https://daa.asn.au/smart-eating-for-you/smart-eating-fast-facts/ nourishing-nutrients/dietary-fibre-a- key-ingredient-in-gut-happiness/ Brain K et al. Healthcare. 2017;5(2). Pain & Sleep • Pain that keeps people awake impairs sleep quality and appetite hormone regulation • Poor sleep affects glucose tolerance and insulin • Leads to an increased risk of type 2 diabetes

Photo by Gianna Ciaramello on Unsplash Pain & Sleep But wait, there’s more! Tired people ... • Make poor food choices • Are too tired to plan ahead • Use food or alcohol to help get back to sleep • Use food and/or caffeine to help stay awake http://blogs.einstein.yu.edu/wp- content/uploads/2012/04/sleepless-clock.jpg Pain & Sleep But wait, there’s more! Tired people ... • Make poor food choices • Are too tired to plan ahead • Use food or alcohol to help get back to sleep • Use food and/or caffeine to help stay awake Considerations for optimising nutrition

1. Reduce inflammation and protect from oxidant damage • Improve food habits so vitamin & minerals reach recommended • Assess fat quality and optimise omega-3 intake • Fibre 30g/day • Water ~2L/day 2. Optimise lean body mass and lose body fat • Protein ≥1g/kg • Healthy fats (monos and poly) and <7% saturated • Carbs (complex) make up the remainder 3. Consider existing medical problems (high blood pressure & depression/anxiety) 4. Be palatable, affordable (unemployed), easy to prepare and sustainable Managing body weight . Manage body weight (aim for 5-10% total body weight) . Lose body fat ( waist reduction) . Optimise lean body mass (see physiotherapist &/or exercise physiologist)

Medical Nutrition Therapy targets an appropriate level of energy restriction to optimise adherence Approach may change over time Managing body weight

Balance between kilojoule restriction versus ability to ‘stick with it’

Easy +++ + Minor 1. Australian Dietary Guidelines

2. RED - reduced energy diet, 2000-4000kJ less/day

3. LED - low energy diet, 4200-5000kJ/day

4. VLED - very low energy diet, 1800- 2500kJ/day Hard + +++ Major

Adherence Energy restriction Managing body weight

Adherence

+++ + +++ +++ Easy - Minor Easy to adhere Large kJ restriction 6x

Energy restriction

Hard to adhere No kJ restriction Hard - Minor Hard - Major + + + +++ Key messages…so far

1. Nutrition is important in chronic pain 2. People need help to improve nutrition 3. Assess malnutrition risk and diet quality 4. Nutrient needs are higher. Focus on healthy eating for pain What is the current evidence on nutrition and chronic pain? A/Professor Tracy Burrows PhD, B Nutr&Diet (Hons I), AdvAPD NHMRC Research Fellow A/Professor School Health Sciences (Nutrition and Dietetics) Faculty of Health and Medicine, UON Brawn Fellowship The University of Newcastle @DrTracyBurrows What does the literature tell us?

• While several reviews exist they are limited

• Only focus on one aspect of diet (e.g. supplement use)

• Populations only experiencing one pain related condition (e.g. arthritis or fibromyalgia)

• Single population groups & small sample sizes

And….no systematic review which put it all together What does the literature tell us?

• While several reviews exist they are limited

• Only focus on one aspect of diet (e.g. supplement use)

• Populations only experiencing one pain related condition (e.g. arthritis or fibromyalgia)

• Single population groups & small sample sizes

And….no systematic review which put it all together Systematic review: Methods • Eight databases (1980-Dec 2017) • Adult pop’n with chronic pain • A dietary intervention • Measure of pain

• Primary outcome: change in pain severity

• Study quality: Assessed using Meta analysis Academy of - Pain (VAS) Nutrition & - Diet Dietetics tool Systematic review: Results • Quality: Positive (n=31), neutral (n=36), negative (n=4) • Country: Majority USA • Study design: Majority RCT • Number of participants: median 48 (range 12-2121) • Most included both males and females • Reported mean age 33-66 years • Reported mean BMI 18-36kg/m2 • 58% participants fell into the o/w or obese BMI category • Approx. half studies identified were > 10yrs • Top three chronic pain related conditions: Rheumatoid arthritis, osteoarthritis & fibromyalgia Systematic review: Results

Regime Examples N = sig ↓ in Other pain studies Altered • Vegan (n=7) No diff =2 overall diet • Vegetarian (n=3) 12 (n=16) • Med diet (n=2) W/in = 2 Altered • Reduction in fat (n=2) specific • Fibre (30.5g/day) No diff = 1 2 nutrient • Protein composition (80g/day) W/in = 1 (n=5)

Supplement • Omega-3 fatty acids (n=9) s (n=46) • Multivitamin &/or mineral (n=5) No diff = 25 11 • Antioxidants, amino acids, W/in = 10 glucosamine &/or chondroitin

Fasting • Pre-fasting period (800kcal/day) No diff = 1 therapy for 2 days followed by a week of 1 (n=4) fasting (300-350kcal/day) W/in = 2 Systematic review: Results

Diet does make a difference in reducing pain (reported by VAS) -0.905 (95% CI -0.537, -1.272), p<0.001 Systematic review: Results

Diet does make a difference in reducing pain (reported by VAS) -0.905 (95% CI -0.537, -1.272), p<0.001

Fasting Altered diet -0.056 -1.415 p=0.030 p=0.863

Single nutrient -1.415 p<0.001

Supplements -1.213 p=0.001 Systematic review: Conclusion • Nutrition can help to reduce pain

• Current research exploring nutrition & pain lacks focus on chronic pain leading to heterogeneity

• Many studies > 10 years old and poor or neutral quality

• Very few studies (<12%) followed up pain measures

beyond the intervention Brain K, Burrows TL, Rollo ME, Chai LK, Clarke ED, Hayes C, Hodson FJ, Collins CE et al. A systematic review and meta-analysis of nutrition interventions for chronic noncancer pain. Journal of human nutrition and limiting long term follow up dietetics: The official journal of the British Dietetic Association. 2019;32(2):198-225. Systematic review: Conclusion • Nutrition can help to reduce pain

• Current research exploring nutrition & pain lacks focus on chronic pain leading to heterogeneity

• Many studies > 10 years old and poor or neutral quality

• Very few studies (<12%) followed up pain measures

1. Nutrition is important in chronic pain 2. People need help to improve nutrition 3. Assess malnutrition risk and diet quality 4. Nutrient needs are higher. Focus on healthy eating for pain 5. Current evidence limited and heterogeneous What is the optimal dietary pattern for chronic pain and how should it be assessed Dr Katherine Brain PhD, B Nutr&Diet (Hon I) Research Academic Priority Research Centre for Physical Activity & Nutrition School of Health Sciences Faculty of Health and Medicine @Dr_KBrain The University of Newcastle Feasibility study

Aim: Test feasibility and efficacy of conducting a food behavior lifestyle intervention with patients experiencing chronic pain who attend Hunter Integrated Pain Service (HIPS) Methods

42 participants 60 participants completed (70% retention) started Baseline 6 weeks Outcomes measured: - Pain outcomes (Brief Pain Inventory, Pain Self-Efficacy, Pain Catastrophising and Visual Analogue Scale) - Quality of life (SF-36) - Dietary intake and diet quality (Australian Eating Survey) Methods

Participants randomised into 1 of 4 groups: 1.Personalised dietary telehealth consult + bioactive juice (cherry) 2.Personalised dietary telehealth consult + placebo juice (apple) 3.Waitlist control + bioactive juice (cherry) 4.Waitlist control + placebo juice (apple) Methods Juice: • 1X 250ml bottle/day for 6 weeks

Personalised dietary telehealth consult: • Developed using the Behaviour Change Wheel • Incorporates a Personalised Nutrition Questionnaire and corresponding Toolbox • Three sessions via phone or Scopia (video coaching), approx. 7-10 days apart • Discuss results from Australian Eating Survey • Brief education on key nutrients for pain management • Set goals and strategies • Summary of session and relevant resources emailed Results: Pain No group-by-time effect for any pain outcomes

All groups had a statistically Groups collapsed (PDC vs WLC) the significant improvement in: PDC group had clinically meaningful results in: -Pain interference -0.9±0.3, p=0.003 -Current Pain (VAS) Reduction of ≥2.5-3cm -Pain self-efficacy +6.2±2.2, p=0.004 -Pain interference Reduction of >1 point -Pain catastrophizing -3.8±1.8, p=0.046 -Pain self-efficacy -Increase of ≥ 7 points and movement to another severity category Results: Quality of life

No group-by-time effect for any quality of life outcomes

All groups had a statistically significant improvement in 6 of 8 QoL outcomes: - Physical function - Physical role limitations +8.1±3.4, p=0.016 +20.6±5.6, p<0.001 - Emotional role limitations - Emotional wellbeing +27.1±7.0, p<0.001 +8.7±2.8, p=0.003 - Social functioning - General health +8.7±2.8, p=0.003 +8.3±2.2, p<0.001 Results: Dietary outcomes

Group-by-time effect: Reduction in % energy coming from total fat • PDC and bioactive juice significant reduction: 5.7±2.3%, p=0.024 • Also significant for PDC group when collapsed: 3.83±1.71, p=0.013

All groups had a statistically significant improvements in: - Energy intake - % Energy from core foods -788±364kJ, p=0.043 +5.2±1.4%, p<0.001 - % Energy from energy-dense, nutrient-poor foods -5.2±1.4%, p<0.001 Results: Process evaluation Overall study satisfaction (total n=42)  n=35 satisfied or very satisfied  n=7 neutral

Those in the PDC group and completed the study All participants (n=16) agreed or strongly agreed that the AES personal nutrition report was:  Useful  Helped identify areas of diet that could be improved  Helped identify areas already doing well  Provided enough information to guide changes to dietary intake Results: Process evaluation Participants (n=16) agreed or strongly agreed that being involved in the personalised dietary consults encouraged them to :

 Consume more fruit and vegetables (n=16)  Change food products they commonly purchase (n=15)  Set nutrition goals (n=15)  Consume less energy-dense, nutrient-poor foods (n=14)  Read nutrition labels (n=14) Conclusions • All groups had improvements in perceived pain, quality of life and dietary intake • Improvements in pain interference and pain self-efficacy were clinically meaningful in the two groups receiving PDC • Pilot study demonstrates potential benefits from providing people who experience chronic pain with a personalised dietary intervention using telehealth • Provides data to inform sample size calculations for a larger multicentre trial to determine the efficacy • Motivators and barriers which may have contributed to the results of the current Brain K, Burrows TL, Rollo ME, et al. The Effect pilot study need to be considered to of a Pilot Dietary Intervention on Pain improve trial design and success of future Outcomes in Patients Attending a Tertiary Pain Service. Nutrients. 2019;11(1). studies Key messages…so far

1. Nutrition is important in chronic pain 2. People need help to improve nutrition 3. Assess malnutrition risk and diet quality 4. Nutrient needs are higher. Focus on healthy eating for pain 5. Current evidence limited and heterogeneous 6. People are interested in nutrition Putting it all together Putting it all together Putting it all together Putting it all together Putting it all together Putting it all together © Katherine Brain 2018 https://www.iasp-pain.org/GlobalYear

1.Reduce inflammation by increasing quantity and variety of fruit & veg 2.Consume good quality fats 3.Prevent vitamin & mineral deficiencies 4.Consume plenty of water 5.Increase fibre intake 6.Reduce and limit ultra processed foods and sugar intake Key messages

1. Nutrition is important in chronic pain 2. People need help to improve nutrition 3. Assess malnutrition risk and diet quality 4. Nutrient needs are higher. Focus on healthy eating for pain 5. Current evidence limited and heterogeneous 6. People are interested in nutrition 7. Relationship between nutrition and pain is complex 8. Nutrition interventions run by dietitians needs to be considered Q & A

“It’s a light bulb moment, learning that there are foods …that’s got nothing to do with weight; it’s got something to do with pain”

@ProfCCollins; @DrTracyBurrows; @Dr_KBrain Continue the Conversation

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