By some estimations, nearly a quarter of Americans suffer from chronic pain. And, to hear the Internet tell it, the right diet can help you control these afflictions, which is why we’re bombarded with everything from ads for magical nutritional supplements to articles extolling the virtues of this superfood or that. But what does science have to say about the connection between food and pain? The Social Brain Blog interviewed Kiran Rajneesh, M.D., a leading neurologist and interventional pain medicine expert at Ohio State University. Rajneesh will be participating in a panel at the upcoming Fourth Annual Brain Health and Performance Summit, presented by the Ohio State University Wexner Medical Center Neurological Institute and the Stanley D. and Joan H. Ross Center for Brain Health and Performance.
Kiran Rajneesh (KR): While we do have big studies about diet in relation to heart disease, stroke, and diabetes, there are no big studies establishing what kind of diet is good or bad for chronic pain. At the same time, chronic pain is extremely prevalent: Up to 75 percent of the patients who come into our office suffer from some form of pain, but it’s less clear what they should be eating or avoiding. We see a lot of publicity out there, a lot of advertisements for products promising pain relief, but there’s not much data to support that.
Wellness is all about lifestyle modification. It’s exercise, personal hygiene, sleep hygiene, discipline, and diet. So we need to do more research about what sort of diet would be optimal to manage chronic pain.
SBB: Still, can you give us some tried and true observations of diet and its relation to chronic pain? Are there some foods that you should absolutely avoid? Are there any that help?
KR: Antioxidants are great. So follow the old adage that fresh, leafy vegetables and fruits with complex carbohydrates are better than simple sugars. Antioxidants definitely have a big role in chronic pain reduction. Oxidants use the three oxygen radicals, which can destroy membranes and predispose you to pain, or keep the cycle of pain going. Antioxidants neutralize or counteract the oxidants in the body. Another dietary staple—coffee—can be good in moderation. In excess, it can bring on headaches and disrupt your sleep cycle, but one cup of coffee may help alleviate muscle tension. Now, there are more esoteric supplements, like turmeric. In eastern cultures, meat is washed in turmeric before cooking, because it kills the bacteria. When I operate on patients, I apply a solution before I start the procedure, because it kills the bacteria on the surface of their skin. Turmeric does something very similar to that. Turmeric is both a good natural substance with which to wash your fruits and vegetables, and it can help chronic pain. We also believe that it has some anticancer properties. Other spices in small amounts have been shown to be effective as well. For example, cinnamon can lower your blood sugar, which can help chronic pain, because chronic pain worsens in people with preexisting conditions, whether it's diabetes or high blood pressure or stroke, or back surgery. The primary mechanisms of action are not necessarily understood, but we do know it helps.
SBB: And for something that we should absolutely avoid?
KR: Energy drinks are really bad. They contain a lot of substances in amounts that exceed our bodies’ needs. They have an extraordinary amount of caffeine, and they also have a lot of neuro stimulants in them. Those are really bad for chronic pain because they disrupt your brain and your sleep cycle. They also increase muscle tone, and caffeine can sometimes contract blood vessels, so then the blood vessels in your brain or other parts of the body can get constricted and do not get enough nutrients or oxygen. This can cause pain and headaches.
SBB: So you see a lot of patients who have chronic pain and consume energy drinks?
KR: Yes. Because what happens is that the ads say that it keeps you active for two to four more hours. Chronic pain patients often have low energy, and these drinks are one way to boost that. Unfortunately, these drinks are actually hurting them by disrupting their muscle tone, blood flow, and their sleep rhythm, all of which make chronic pain worse in the long run. That's a common one. Also bad are drinks with a lot of sugar, particularly sodas that have both a lot of sugar and a lot of caffeine. Even decaf coffee can exacerbate chronic headaches if you drink enough. Something that’s really good, on the other hand, are nuts. Nuts contain essential oils and antioxidants that decrease peroxidation in the cell membrane.
SBB: Do the same ideas apply to people who don't suffer from chronic pain? Should they eat and avoid the same things?
KR: Yes. And that goes back to that adage of “anything is good in moderation.” So, for example, for people with chronic headaches, we may say, “Don't drink two or three cups of coffee, maybe one cup.” And, if they still have headaches, we may say, “Just drink decaf.” And, if they still continue to have headaches after removing caffeine, then we would start treatment with medications. So, on the flip side, for someone without chronic pain, I would say no more than two or three cups a day. I would say the same with fruits and vegetables—they not only prevent chronic pain, but they are an essential part of our well-being. We want the younger generation, our kids and teenagers, to eat green, leafy vegetables, fruits, and nuts so they get a good dose of antioxidants. This will prevent later development of chronic pain, because one of the ways chronic pain develops is the persistence of acute pain. So, if you're a healthy person, if you have acute pain like if you stubbed your toe or got into a motorcycle accident, you will recover more quickly if your diet is healthy. So, it is crucial for pain prevention that people, including young and healthy people, pay attention to their diets.
SBB: I haven't heard anything about meat, dairy, or gluten, which obviously come up in a lot of discussions. What are your feelings about them?
KR: We have seen an association between high cholesterol and chronic pain, because it can create a constant state of inflammation in the body, making chronic pain more difficult to treat, and injuries more difficult to heal. There are not any big studies, but a large amount of red meat consumption is probably not great for chronic pain, because it can be inflammatory. This is similar to smoking. I always tell my patients if you smoke or you eat a lot of meat, you have a lot of lipids circulating in your body. If we give them a pill like NSAID (Ibuprofen), it won't be able to zero in on the joint that’s inflamed, because your whole body is inflamed due to smoking or lipids.
Dairy is good for most healthy people. It has a great amount of calcium so, in the right amount, it’s good for growing children and for overall health. But in some conditions, dairy can make things worse, especially for chronic headaches. One thing we tell our chronic headache patients to avoid is cheese and dark chocolate, which both contain some dairy. We don’t know the exact reason, but they do tend to keep the cycles of headaches alive.
For gluten, I’ve seen it contribute to some abdominal and pelvic pain. This bears out a theory suggesting that our bodies have not evolved to eat the amount of grain that we are currently consuming. We had a food shortage in the 70s and 80s, and we hybridized a lot of crops, increasing the amount of grains we eat in our diet. There are some theories that show, at least in mouse models, that grains can cause inflammation of the bowel. So while a certain amount of grains is necessary for some essential micronutrients, we are probably eating much more than what we were actually evolutionarily designed to eat.
SBB: Opioids are obviously the center of a lot of discussions around chronic pain, and the big question is, “Do we prescribe opioids too soon and too frequently?” Do you suggest specific lifestyle changes before prescribing them?
KR: Absolutely. For chronic pain, and all of medicine actually, the first thing we want to target if the patient is not high-risk is lifestyle modification. That means looking into their sleep patterns and their sleep hygiene, looking at their diet, looking at their weight, looking at the amount of activity they're doing, in terms of exercise, but also activity modification.
For example, say you’re a computer engineer and you come to me for neck pain. The first thing I ask them is how often they stand up and stretch at work, or if they have a desk that moves so they can stand while they program, or an ergonomically designed chair or monitor that would prevent repetitive stress injury to the neck. They may not even need acetaminophen or ibuprofen. I think that should be the goal.
I think the foundation of a good approach to healthcare is lifestyle modification. And then, when lifestyle modifications fail, or the patient is too sick to engage in them, that’s when we think of other things—physical therapy or some kind of supervised activity and exercise. And if that fails, then we look at non-opioid medications. If those fail, then we look at interventions, and if those fail, that’s when we should be looking at chronic opioid therapy. Sometimes we have patients who are not surgical candidates, and opioid prescriptions can be helpful. These are the guidelines from our pain societies, it’s what we teach our fellows. So, while some patients may need opioids, the vast majority do not, and one of the strategies I suggested may help them be functional enough to enjoy a good quality of life without medication.
SBB: Why do you think we are in the midst of this crisis? Are people not following the guidelines?
KR: This is all about history. In the 1980s, the WHO (World Health Organization) created the pain ladder. This was a three-step ladder that suggested initial care of chronic pain with non-opioid medications, and then a move to low-potency opioids, and then to high-potency opioids, as needed. Then our healthcare system began viewing pain as a vital sign, dictating that no patient should leave a health-care facility in pain if medication is available to treat pain. So a lot of the older physicians were taught in their residencies and fellowships that they should prescribe these medications because we didn't know how deadly they would be in the long term. They were great for a short term fix.
But lifestyle change can be difficult. I often struggle to get eight hours of sleep a night. So some of these suggestions are really difficult to incorporate, and they're even more difficult if you have a patient that has diabetes, a poor heart, a bad liver or knee. So I think most prescribers were doing so to help patients and alleviate pain, and then 10-15 years later we are in the middle of the epidemic. We’re now understanding that these medications are great for a short term fix, like a week after surgery or when you have a motor vehicle accident. But they are not great long-term medications, because they have so many side effects.
My hope is that a focus on well-being would be built into our culture, especially for our young people. We need to remind young people that their own bodies have a great capacity to heal. And, for older people, we need to educate them that these pain medications should not be used long term. On the legislation side, I think we need more research to get new molecules to find new ways to treat pain. And, on the industry side, we need a robust wellness industry based on data, rather than the current paradigm, which is largely unregulated. I am optimistic. There is a growing awareness of the dangers of opioids. There is also a lot of good legislation and policies being made through state medical boards. In addition, schools are changing their curriculums to include education about wellness and health. So I think we'll see some great progress over the next decade.
Premier will host a 6 day Chronic Pain Self-Management workshop on June 9, 16, 23, 30, July 7 and 14. For more information go to our events page
Kiran Rajneesh, M.D., is a board-certified neurologist and pain physician at The Ohio State University Wexner Medical Center