Eating & aching: the symbiosis between discomfort and nutrition

Chronic discomfort and nutrition have an impact on each other that radiates throughout every area of daily life.

The Australian Institute of Health and Welfare identifies lower back pain and arthritis as the two most common reasons for loss of quality of life, and cites that 1 in 5 Australians will suffer with chronic pain at some point in their lifetime.

Every nurse is likely to care for patients with chronic pain on a regular basis. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage”. Chronic pain is a distinctive disease, it causes changes throughout the nervous system and has psychological effects. This makes it difficult to see and challenging to treat.

All pain is entirely initiated and produced in the brain. Neural impulses provide stimulation, which the brain collates and interprets. If it is determined that there is something wrong, pain will be instigated. It is a protective mechanism that encourages the individual to stop or change their behaviour, not a measure of physical injury.

In deciding if pain is a “useful” response or not, the brain considers many factors. Current situation, emotions and anxiety levels, past experiences and future expectations are all deliberated. Pain is, therefore, entirely subjective, and only the person experiencing it can truly appreciate it or describe the intensity or accompanying sensations.

Acute pain usually occurs following trauma or injury, it lasts less than three months and timely treatment prevents acute pain from becoming chronic pain. Evidence indicates that the initial 24 hours following trauma are pivotal in the intensity, recovery period and long-term prognosis.

Chronic pain is defined as lasting three months or more and as pain that may not have a clear aetiology. By this time, most body tissues have healed, but the brain continues to produce pain. In this case, it is not usually related to tissue damage, but rather to the sensitivity of the nervous system.

Body weight is an important predictor of pain, particularly in the lower back, but few appreciate the impact of pain on body weight, nutrition and chronic disease. Pain changes nutrient requirements, what people choose to eat and how they are able to access food. Pain affects all areas of a person’s life, including work, sleep, sex, exercise and self-care. Here are some examples.

Mobility

Pain affects mobility and agility. It can hinder a person’s capacity to perform activities of daily living, including shopping, cooking and preparing food. The nutritional value of food is subsequently pushed down the priority ladder in favour of what is readily available and requires the least amount of effort to obtain and prepare.

The act of eating or digesting food may also be painful. Acidic, dry, salty or spicy foods may cause irritation to the mouth or an intolerance may limit the types of foods selected due to abdominal cramping or bloating.

Medications

Medical management of chronic pain often involves a variety of medications, treatments or interventions. Since pain pathways are multifaceted, best practice involves a multi-modal approach. Regarding medication, it is common to use a combination of opiates, non-steroidal anti-inflammatories, paracetamol, antispasmodics, anticholinergic agents or anti-depressants.

Some medications used to relieve pain affect nutrition. Common side effects include nausea and vomiting; constipation; taste changes; appetite changes; dry mouth. Managing these side effects early reduces the overall influence on a person’s nutritional status and improves their long-term prognosis and tolerance for treatment.

Psychological effects

Pain has a large psychological influence. Heightened levels of stress and fear of pain increase the sensitivity of the nervous system, intensifying or exacerbating painful sensations.

Nutritionally, pain management may override eating in the priority stakes, increasing risk of weight loss and malnutrition. Conversely, for someone who feels chronic pain restricts their lifestyle, food may be perceived as the only enjoyable thing in life, leading to increased intake and subsequent weight gain. This, in turn, has the potential to exacerbate pain and further its destruction on the person’s daily life.

Weight changes

Chronic pain can cause a drop in activity, leading to a reduction in lean muscle and reduced resting energy expenditure, thereby limiting the ability to engage in physical activity. This often results in weight gain and intensified pain.

Many people also report eating less during times of pain, because either the pain or medications override appetite. If this is ongoing, weight loss and malnutrition are a concern, reducing immunity, tolerance for treatment and overall quality of life.

Sleep

The impact of sleep on health is often underestimated. Pain has a major impact on a person’s ability to get to sleep and stay asleep. Lack of proper sleep affects hormones, including Cortisol and growth hormone; this leads to impaired glucose tolerance and risk of type II diabetes.

Leptin and ghrelin, the hormones responsible for regulating appetite, are affected by lack of sleep as well. Further, people who are tired may use food or caffeine to stay awake, and may be too tired to plan, shop or prepare food, leading to poor food choices in favour  of convenience.

Nutrition makes a difference

Ensuring adequate protein intake can help maintain muscle mass, strength and mobility. This helps to achieve and maintain a healthy body weight, and reduce risks associated with unintended weight loss and malnutrition.

Most of the research into dietary interventions to manage pain is on Omega 3. This type of fat can increase production of anti-inflammatory cytokines and block production of pro-inflammatory cytokines. Research has found that diets high in Omega 3, including those supplemented with up to 3mg a day for a minimum of three months, can decrease patient-assessed pain and the use of non-steroidal anti-inflammatory drugs.

Pain is complex and management is multi-modal. Providing best-practice, patient-centred care involves a multidisciplinary team. An accredited practicing dietitian (APD) is a university-qualified food and nutrition expert and, for those with chronic pain, can play an important role in achieving and maintaining optimal health and wellbeing.

Joanna Baker is an accredited practising dietitian and registered nurse.

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