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Joseph Walker III, MD Department of Orthopedics

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1 Nutrition and eating behavior in patients with chronic pain receiving long-term opioid therapy
Joseph Walker III, MD Department of Orthopedics University of Connecticut

2 Prevalence of chronic pain
Background Prevalence of chronic pain Developed countries: 19-37% Developing countries: 41% Adapted from Windt et al. J Psychosom Res 2008

3 Objectives Objectives Objectives of this study
Previous studies suggest a correlation between nutrient intake and chronic pain However, the lack of clinical research regarding the dietary behavior of patients with chronic pain has been noticeable Objectives Objectives of this study To assess nutrient intake and eating behavior in a group of patients who were diagnosed with chronic pain and received long-term opioid analgesic therapy

4 Inclusion criteria Methods Inclusion criteria Exclusion criteria
At least 18 years old Intractable chronic pain Long-term opioid analgesic treatment Exclusion criteria Previous eating disorders Pregnancy Methods

5 Demographic and clinical data of participants
Characteristics Value ± SD Sample size, n 53 Men (%) 30 (57) Women (%) 23 (43) Age, y 54.7 ± 11.3 White (%) 51 (96) American Indian (%) 2 (4) Mental Health Diagnosis (%) 19 (36) Methods Meleger et al PMR 2014

6 Demographic and clinical data of participants
Characteristics Value ± SD Chronic Pain Diagnoses Low pack pain ±Lumbar Neck pain ± Cervical Neuropathic pain (Peripheral, Central, CRPS) Joint pain (psoriatic, degenerative) Fibromyalgia Poststemotomy pain Perineal pain Post-traumatic jaw pain 30 9 2 1 Pain Level 0-10 5.8 ± 2.2 Average Morphine equivalents, mg 226.6 ± 199 Duration opioid treatment, y 1.5-14 Methods Meleger et al PMR 2014

7 Overweight (BMI ≥25 - <30), N (%)
Demographic and clinical data of participants Parameter Value ± SD BMI, X ± SD 29.3 ± 6.1 Overweight (BMI ≥25 - <30), N (%) 14 (28) Obesity (BMI ≥ 30), N (%) 22 (44) Methods Meleger et al PMR 2014

8 Experimental setup Methods Meleger et al PMR 2014

9 Study instruments Methods
Pain Intensity during 6 months Numeric rating scale and visual faces scale (Wong-Baker Faces Rating Scale) Methods Biosphychosocial information Short demographic survey

10 Study instruments Methods
Nutrient data 14-item Food Frequency Questionnaire (FFQ) -Type of foods they consumed -Quantity of those foods in relation to a medium sized portion Nutrient calculations Nutrient data system for research software (2010) -Generates multiple datasets from a batch of completed FFQ forms, including the daily nutrient intake dataset Methods Eating behavior Eating behavior inventory (EBI) -26-item self-report instrument developed to asses individual behaviors that have been implicated in weight-loss management

11 Weight distribution and caloric intake
Results Note: 6/30 men and 6/20 women reported a daily caloric intake below 1200 calories per day Meleger et al PMR 2014

12 Mean individual daily consumption
Results Nutrient Mean ± SD Recommended Carbohydrates (%) 51 45-65 Protein (%) 16.3 10-35 Fat (%) 34.1 20-35 Meleger et al PMR 2014

13 Mean individual daily consumption
Nutrient Mean ± SD Recommended* Carbohydrates (g) (kcal) 240.6 ± ± 420 Sugar, total (g) 125.6 ± 59.6 130 Sugar, added (g) 74.4 ± 43.0 Restrict Intake Glycemic Load 117.7 ± 54.7 90 Fiber (g) 17.3 ± 7.5 25 Aspartame (mg) 145.9 ± 300.5 Results * Recommend/Guidelines from USDA Dietary Reference Intake Meleger et al PMR 2014

14 Mean individual daily consumption
Results Meleger et al PMR 2014

15 Mean individual daily consumption
Nutrient Mean ± SD Recommended* Cholesterol (mg) 266.5 ± 234 < 300 Saturated fat (g) (%) 25.8 ± 16.8 12.3 < 16 < 7 Omega-3-fatty acids (g) 1.6 ± 0.99 Prevention cardiovascular disease: >0.3 Modulation of RA pain: (RA) Total trans-fatty acids (g) 2.7 ± 1.7 1.3 < 2.0 < 1.0 % Total monounsaturated fatty acids (g) 25.7 ± 14.6 Total polyunsaturated fatty acids (g) 14.4 ± 8.3 (14-17g /day) men (11-12g /day) women Results * Recommend/Guidelines from USDA Dietary Reference Intake Meleger et al PMR 2014

16 Mean individual daily consumption
Results Meleger et al PMR 2014

17 Daily consumption of fruit and vegetables
Daily Serving Mean ± SD Recommended* Fruit (5-a-day method) 1.5 ± 1.2 4-5 Fruit (summation method) 1.8 ± 1.1 Vegetables (5-a-day method) 1.9 ± 1.4 Vegetables (summation method) 1.9 ± 1.5 Results * Recommend/Guidelines from USDA Dietary Reference Intake Meleger et al PMR 2014

18 Daily consumption of Alcohol and Caffeine
Results Daily Consumption Mean ± SD Recommended* Alcohol (g) 1.6 ± 0.5 < 14 Caffeine (mg) 199.9 ± 160.8 < 186 * Recommend/Guidelines from USDA Dietary Reference Intake Meleger et al PMR 2014

19 Daily consumption of Tryptophan
Mean ± SD Tryptophan (g) 0.9 ± 0.4 Results Meleger et al PMR 2014

20 Daily consumption of vitamins
Mean ± SD RDA (Men) RDA (Women Vitamin A (mg) ± 900 700 Vitamin C (mg) 112.7 ± 72.0 90 75 Vitamin D (IU) 244 ± 208 600 Vitamin E (mg) 14.3 ± 13.8 15 Vitamin B12 (mg) 8.6 ± 10.2 2.4 Folate (mg) 436.7 ± 222.0 400 Results * Recommend/Guidelines from USDA Dietary Reference Intake Meleger et al PMR 2014

21 Daily consumption of vitamins
Results Meleger et al PMR 2014

22 Daily consumption of minerals
Results Meleger et al PMR 2014

23 Daily consumption of minerals
Mean ± SD RDA (Men) RDA (Women Calcium (mg) ± 672.1 1000 Magnesium (mg) 293.6 ± 120.4 420 320 Iron (mg) 15.2 ± 8.8 8 18 Sodium (mg) ± <2300 Results * Recommend/Guidelines from USDA Dietary Reference Intake Meleger et al PMR 2014

24 Conclusions Conclusions Calorie intake Clinical conclusion
Our results suggest a similar percent of fat, protein, carbohydrate calorie intake However, regarding type of fat intake, the participants reported greater than recommended saturated fat and trans fat consumption compared to guidelines Conclusions Clinical conclusion Counsel the patient on reducing saturated fat and transfat intake and to bring more in line with guidelines

25 Conclusions Conclusions Vegetable intake Clinical conclusion
Participants consumed an approximate daily average of 2 servings of fruits and vegetables, respectively This is well below the suggested daily guidelines of 4-5 servings in each category as proposed by the American Heart Association and the Dietary Approaches to Stop Hypertension diet Conclusions Clinical conclusion Counsel the patient on raising vegetable intake

26 Conclusions Conclusions Sodium Intake Clinical conclusion
Sodium intake was found to be significantly higher than the conservative suggestion of 2.3 g per day Conclusions Clinical conclusion Counsel the patient on lowering sodium intake

27 Conclusions Conclusions Caffeine Intake Clinical conclusion
All but one participant reported a higher regular consumption of caffeine than the average consumption in Vermont Conclusions Clinical conclusion Counsel the patient to lower caffeine intake, since there is a possible relationship with poor sleep/insomnia

28 Conclusions Conclusions Omega-3-Fatty Acid intake Clinical conclusion
The majority of participants consumed more than the recommended Cardiovascular protective dose of omega-3-fatty acids, but less than the anti-inflammatory dosing found to be effective in persons with RA Conclusions Clinical conclusion Counsel patients with RA to increase their daily dosage via fish, nuts, and seeds

29 Conclusions Conclusions Vitamin and Mineral intake Clinical conclusion
Results from the present study indicate suboptimal intake of micronutrients, especially vitamin D and Magnesium Conclusions Clinical conclusion Counsel the patient to increase/balance their intake of magnesium and vitamin D

30 Conclusions Conclusions Eating Behaviours Explanations
Our results demonstrate a pattern in average EBI scores that is very similar to the scores for new patients entering a weight-loss management centre Conclusions Explanations -Participants have eating behaviours that promote weight gain -Participants have eating behaviours that do not promote weight loss Clinical Conclusion Physician may wish to direct patients to weight-management

31 Conclusions Conclusions Artificial Sweetener Intake
Participants had high intake of artificial sweeteners such as aspartame Conclusions Clinical Conclusion Consult patients with fibromyalgia or headache disorders that minimizing/ stopping this high intake may relieve their symptoms

32 Conclusions Conclusions

33 Future Perspectives Future Perspective Study limitations
Small sample size Sampling bias Small ethnic heterogeneity Long-term opioid analgesic therapy Future studies Large prospective population studies are needed to confirm our results in patients with or without opioid analgesics Future Perspective

34 Acknowledgements Dept. of Physical Medicine and Rehabilitation
Harvard Medical School Boston, MA and Spaulding Rehabilitation Hospital Medford, MA Marriage and Family Therapy Program Human Development and Family Studies University of Connecticut Storrs, CT Cameron Kiely Froude, MA Alec L. Meleger, MD Spaulding Rehabilitation Hospital Medford, MA Virginia Czamowski, NP Supported by: Spaulding Rehabilitation Mini-Grant

35 FIN Meleger AL, Froude CK, Walker J. Nutrition and eating behavior in patients with chronic pain receiving long-term opioid therapy. PM&R Jan; 6(1):7-12.


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