Impact of Diet Quality and Nutrients on Chronic Pain


[ Applause ]>>So yeah, good afternoon. Thank you for being here
and being excited so late in the day especially when
we’re going to be talking about diet quality and thinking about what we’ve been
eating throughout the day. So as he said I’m Susie Zick. For those of you who don’t
know I’m in Family Medicine and Nutritional Sciences
and like Andrew, this is a brand-new
field and just to let you know these data
analysis that we’re looking at literally I was
getting data on Friday. So this is hot off the press
stuff and it’s very preliminary at looking at this and we’ll
certainly raise more questions than answers just like Andrew. And I’m going to thank
Andrew and the other speakers for doing some background
work for me so I can save some time as well. So first I have no financial
conflicts but I also wanted to talk about my team,
some of which are here. One is Justin Colasino,
who helped me with the Haynes data
environmental health sciences there. And the other group is
the Miles group that works on Lupus including
my MS student, Kevin, who is back there, and Tracy
who is one of the smiling people in the Miles group there, without whom we would
not have this data and this analysis today. So thank you so much
to the team. So we just talked about
quantity, and I’m going to be talking about quality
and that they’re kind of two although interrelated but
also kind of separate topics, and it’s good to keep
that in your head. So what do we really
mean about diet quality? So I gave this example here
of two pieces of bread. One of them would be
normal white bread that most of us eat the other one is 100%
whole grain or whole meal bread. You can see that both of them
have roughly the same number of calories, but they have
a very different nutritional density or content in terms
of protein, fiber and vitamins and minerals all of which the
whole grain one despite having essentially the same
calories has quite a bit more and then the white bread
often has added sugars, which are on top of
the natural sugars that you might have
in this product. And so obviously
the whole grain, one even though it
has similar calories, has much better diet quality. So that’s what we’re
really looking at how much nutrient density do
we have per calorie in the diet. So how do we measure
diet quality? So there’s quite a number
of indices out there. One that works really well
in US populations not so well in international populations
is the Healthy Eating Index and the Healthy Eating Index
maps onto the US Department of Agriculture’s recommendation for what Americans should
be eating with it’s a 0 to 100 score, 100
would be ideal. I haven’t met that person. If you know them,
send them my way. And there are several
different versions all the way up to 2015 to 2020. When they make a new
recommendation in 2020, they’ll probably make a
new one that will map to it for the USDA, but we use
the 2010 one in our analyses because we were actually
looking at people from 2010 and so it mapped most nicely to
what they were actually eating and what we collected. And what you will see here
is that the top group there from total fruits to fatty acids
are things that you want to eat. In other words, their adequacy
components and if you eat, say, for example, in the total fruit at least .8 cups per
a thousand calories so these are standardized
calories per day, you would get 5 points. If you ate no fruits,
you would get 0 points and then there’s gradations
all the way in between. In contrast for the moderation
ones, you want to eat no more than or less than what
they’re recommending. So for refined grains less than 1.8 ounce per day would be
an example there, and if you had as much as 4.3, you would
get 0 on your score. So once again you
put this all together and the higher the better. So why is diet quality
important? Yes, we know will probably
your mother or your grandmother or some other relative
told you to eat your fruits and vegetables and so they had
good reasons for that along with your other whole grains,
et cetera, and what we know is that diet quality measured through many different indices
including the Healthy Eating Index is highly associated in
cohort and observational studies and in the case of
Mediterranean diet studies, which can be high-quality
not always, are associated with decreased risk and
mortality in particular through cardiovascular disease
risk and cancer mortality. And you can see there that that
range is anywhere from about 9 to 25% decrease over
the course of 10 years. So that’s a pretty significant
decrease and that’s independent of other risk factors
like smoking, exercise and other things
that we would think about including weight
by the way. So I think it’s important
to understand that these are independent
of things like obesity and overweight. What about symptoms? We haven’t had a lot of
investigations about symptoms. Depression is an exception,
and we know from quite a number of studies this is one of
the more recent meta-analysis that incident depression
is actually lowered about on average about
35% is the association between improved diet
quality compared to those who have the lowest
diet quality. So we also are having
symptom changes that are very important
to people. So how might diet quality
impact chronic pain? Well, first I’m going to tell
you we don’t really know. This is a new category
as I said, but one area that we’re interested in is
about the gut micro biome, which can influence the brain,
at least in animal studies through vagal nerve stimulation
and actually impact levels of neurotransmitters
and conductivity which can change behavior
and increase pain. And we also know through the
HPA axis and inflammation that you have impacts
on the micro biome. We also know that as the micro
biome becomes less diverse, the less healthy it is and the
more you have these negative impacts upstream. So we happen to know that
the more fiber you eat, the more diverse the fiber
you eat, for instance, which is an important part
of healthy eating indices, the more likely you are to
have a diverse micro biome. And we can see there
that the change in the Healthy Eating
Index in humans, these were in healthy humans,
explain the greatest variance of the microbiota composition. This was more so than many
other things that they measured and this was a prospective study
that was looked at through time. So we happen to know that
quality matters to your gut. So I’m going to thank Andrew
for already telling you all about inflammation and pain and how systemic
inflammation can impact pain and calorie restriction,
but independent of calorie restriction,
the quality of your diet, i.e. how much phytochemicals
say from fruits and vegetables, fiber how much things
like healthy fatty acids like polyunsaturated fatty
acids like omega 3s help to decrease inflammation at
several different points here as you can see both systemically
and de novo in the brain, and we also know
that some of these like the omega 3 fatty acids
impact the lipid membranes and how the communication
happens in both the brain and systemically, which is
extremely important a number of symptoms possibly
also in pain. So the first type of
pain that we looked at was actually spinal pain,
and we’re actually going to look at two different types of pain, and you’ll see why we
made that decision. So we actually looked
at the National Health and Nutrition Examination
Survey that the CDC runs and that has been for those
of you don’t know going on since the early 19,
well, the late 1950s where they phenotype
people’s diets really well and their exercise really well and they collect
biological samples and they also do other surveys and every year they
do a new sample. And just to let you know they
have 15 different regions of the countries where they
take on different counties from each of those regions. They then do sampling segments
that go down to household levels and they do one-on-one
interviews all over the course of a few weeks normally
in July face-to-face and amongst those they
always ask a food frequency questionnaire about
what’s typical diet over the course the year as
well as 24-hour dietary recall. So in 2009, they asked a little
over 4000 of their participants about pain in the spine. So they called it an
arthritis questionnaire but by the way they asked them
did you have pain anywhere from the neck, the
upper back all the way down to the hips, yes or no. And so here are the people who said not only did they
have those, but they’d had them for at least three months
and had them continuously. So you can see there
were quite a number of people who attributed those. When we merge those with the
dietary data, we lost some. Not everybody fills out their
questionnaires as we know, and you can see here the
number of sites of people who said they had say just one
site all the way up to 20 people who had all six sites that
gave us 809 individuals who said they had
pain in their spine. So what did they look like
those with pain versus no pain? And what you’ll see is those who had pain were more
likely to be women. Probably not terribly
surprising to us. They were a little older,
they were less likely to be Mexican-American
or Hispanic. Just to let you know Haynes
over samples minorities in particular Hispanics
so it’s kind of an interesting
population to look at and also they were more likely to have a higher BMI
on average as well. So probably other than
the Hispanics not terribly surprising for what
we would be seeing. And were the Healthy
Eating Index, the HEI 2010, different between the
spinal pain versus not pain. So here I’ve outlined in red
where we see the total HEI score and remember all
those component scores from total vegetables all the
way down to added sugars there and what you’ll see is, yes, those who had pain had
significantly lower total diet quality, okay, for the total
score and that was really driven by things like saturated fat and
added sugar and you’ll see there that they have lower
numbers there but remember this
is about adequacy. So if you actually have
a lower score for those that actually means they were
eating more of those as compared to the ones that
you wanted to eat where you wanted a higher score. So people with pain were eating
less fruit, less seafood, less plant protein, more fat and more sugar significantly
compared to those who did not have pain and these
held even though we adjusted for things like BMI. So this is independent of their
weight, age, sex and race. What about macronutrients? So macronutrients are spread out throughout all those
different categories. So it can sometimes be hard to
see this, but for those of you who don’t know what
macronutrients are these fat proteins and carbohydrates
it’s where we get the majority of our calories and
here you can see that saturated fat was driving
this particular difference between the pain, the
spinal pain and no pain with a little bit
higher saturated fat that was significantly
different, but where you really
see the difference is in fiber and sugar. And so you can see there for
the percent calories there are significantly more sugar
intake and less fiber in those with spinal pain, but I
changed those over to teaspoons and grams so that we could
get in some idea here. So just to let you know
grams there by 1000 calories. So if you think about 2000
calories a day you can multiply that by 2. We’ll touch on that a
little bit more and how that is what we’re supposed
to get compared to the USDA and teaspoons there is how
the USDA measures that so that we have some conception
of how much they’re eating. So what the arthritis
questionnaire didn’t do and Haynes didn’t do is they
did not ask one question about diet severity, I
mean about pain severity. So we couldn’t actually say
were any of these associated with the amount of pain
severity just the existence of pain yes or no. So we could ask these
questions though in totally different population,
which is the lupus population, and here you have some
of the main symptoms of this autoimmune disease
one of them which is pain, particular pain in the joints. And so quite a different group
and a group that has a lot of co-occurring symptoms
as well. So what do we find here? So this is from the
Michigan Lupus Epidemiology and Surveillance Program,
which draws a cohort of lupus and frequency match controls for
age, sex and race in a little over 500 people in Washtenaw
and Wayne County here and has been going
on since about 2012, which you actually have these
participants in the studies. And in that study, there
was two measures of pain. There was a sub score on the
RAND SF 36 which is bodily pain and there was also what
we’ve been hearing a lot about the fibromyalgia
scale asked as well. We also asked the
dietary assessment. It was a food frequency
questionnaire that’s been developed by the National Cancer
Institute called Diet History Questionnaire 2. We did with portion sizes. Here’s an example. It’ll ask you in a typical
week how much pizza do you eat and then it’ll ask you what
size of pizza here is more like what you would
actually have. And they ask you that to
kind of average and say in your year what’s your
typical dietary pattern. So it’s a very thick
survey to go through all the different
foods that people eat. So what’s the demographics
of those who have lupus versus those who do not
in our cases and controls because I think it’s
interesting when we talk about any differences in diet
quality across our spinal pain and our lupus patients
and what you’ll see is that you do have more women
who have lupus, which we know for autoimmune diseases. We see that they’re a little
bit younger than the controls and here you see that we
have almost half being African-American in the cases because it is more prevalent
in African-Americans. So a little bit different than
the other group that was rich with Hispanics, and
you can see actually that the BMI is actually
a little bit, although not significantly,
lower in these two groups. So what about the Healthy
Eating Index and diet quality? So once again you see a
significant difference with a lower diet quality
and those who have lupus. Now what you will see here
as compared to the 50s, which is quite a bit lower
here, these are in the 60s. So their diet quality
overall is better than those who have spinal pain. So that’s interesting. And also what you see here is
that the saturated fat, alcohol, and added sugar, the empty
calorie category is what’s driving the difference
between the two groups where you have all
those being even more in the lupus than
in the controls. So that’s similar to
what we were seeing in the spinal category as well. What about those macronutrients? So take a look at that
a little bit more. Sorry and the carbohydrates
got covered up again. So what you’ll see here
is that fat drives a lot of this although interestingly
enough the controls actually ate a higher percentage of fat,
right, than people with lupus, which was different
than in the spinal pain where they ate a little bit more and where you really see the
difference here is in fiber and in added sugar
where you see that 20% of the calories roughly are
coming from added sugar. So that’s not natural sugar
like in fruit by the way. This is added like white sugar
or honey in the lupus versus 17% in the controls, and you have
a lower percentage of fiber. So then we asked well is
this actually associated with anything to
do with pain, okay? So it’s different
but okay so what. So what we did find is that
after adjusting for things like weight, sex, race,
and total calorie intake so this is independent
of all of those that as diet quality score
decreased or got worse, you saw an increase
in bodily pain. So for every .3 essentially
decrease in that score that goes from 0 to 100 you had
a 1 point increase. So you could start
going up quite quickly on the RAND scale as
quality goes down. Then we looked at that by cases
and controls because by the way that one was across both cases
and controls it didn’t matter. And what you found
out that with cases and controls you had
the same pattern. So it was independent of whether or not you were a
case or control. It just had to do with whether or not you actually
reported bodily pain. So if you remember, there was a
difference of about 2.2 points between diet quality between
lupus and control and just to give you an idea that
2.2-point difference just on average led to about a
7-point increase in pain. So on the RAND, you
have to get close to about a 10-point increase
to be clinically significant. So it’s beginning to get
there just on average. So clearly there’s some people
that this might be an issue with and others it would
not depending on it but it’s getting
pretty close there. What about on fibromyalgia? So this is combining the cases
and controls and basically if they said, no, they did not
have fibromyalgia versus, yes, they did, they had significantly
higher for the ones who said no diet quality
versus those who said yes by about 2 points and that
was once again after adjusting for things like weight. When we looked at this
by case-control status, it also did not change. So it did not matter if you
had lupus or you didn’t. Basically you saw
about the same thing about a 2-point lower
diet quality in those who had fibromyalgia
versus those who did not via the
questionnaire. So what can we say in
conclusion about this? Well, first just to give you an
idea during the time this was happening, what did dietary
scores look like across America? You can say they looked
about 59, okay, on average, and they stayed pretty steady
through time in the US diet. You can see it’s a little bit
different by age with those who are the youngest and the
eldest having the best diet quality and really how does
that compare to what we saw? So spinal pain patients
had an HEI of roughly 52. It’s significantly lower
than the US population and that’s despite the
fact that they tend to be a little bit older. Versus the lupus, which
was actually better than the US population
even though they tended to be a little bit
younger and would’ve been in the lower groups there. We saw at least in
lupus patients that poor diet quality
is associated with more bodily pain
and widespread pain. So this is something that
we really need to look at in different populations
and start to think about what mechanisms
might be driving this. This is the first time we’ve
looked at this and just to let you know when you look
in the literature there’s all of three studies that
have looked at whether or not diet quality
impacted any type of pain at all in any population. So that’s pretty low. What about the role of saturated
fat, fiber, and added sugar which was really driving the
differences in the diet quality? So there you have a picture
of common foods both plant and animal that have
saturated fat. According to USDA we should
be aiming for less than 10% of our calories in
saturated fat. Chronic pain was between
11 to 10% of their diet. So they were right on
board of what you’d expect. So maybe not that exciting. What about fiber? So we’re aiming for at least
25 grams per day of fiber there and you can see that they were
significantly lower particularly in the spinal pain group
of 16 to 20 grams per day. But let’s hang out with
sugar for just a little bit. Sorry that we have the
snacks in the afternoon when I’m talking about this. There are three recommendations
for dietary levels of added sugar in the US. One of them is the
USDA which says limit to 10% of your calories. So in a 2000-calorie diet,
that would be 12 teaspoons or 200 calories a day. The World Health
Organization says less than 10%, but ideally 5% of your calories. And so that’s around
6 teaspoons per day. And the American Heart
Association, which is basing it on the fact that added
sugar above these levels by the way is associated
with increased mortality on heart disease and incidence
of mortality, they’re saying that for men 9 teaspoons and
women 6 teaspoons regardless of their calorie intake. So that’s anywhere from 6 to 12
teaspoons, you take your pick, with the lower your calories
and if you’re a woman on the lower side versus men. And by the way if you
want to look on the side of your labels every, you need
4 grams to hit about a teaspoon. So our pain patients were
eating anywhere from 27 to 30 teaspoons of
added sugar a day. This is significantly
higher than recommendations. Just to let you know they
were not hugely higher than the regular population, but they were significantly
higher even than the regular population
which is not great. I just wanted to put this
graphic up here for guys to think about sources
of added sugar. So we think a lot about
desserts, cookies, candies, pies, doughnuts, none
of those are up here, but if a person was just
to have a Snapple, a yogurt and 1/2 a cup of
applesauce and every one of those cubes is a teaspoon by
the way, for breakfast, right, and that’s added sugar that’s
not the sugar in the apples, and then have two pieces of
bread with some of that ketchup on it and some pickles
for your lunch. Let’s assume they put
something on there that has no other added
sugar, which is reasonable for their sandwich, and then
they had the McDonald’s premium crispy chicken club
sandwich for supper. They had no other sugar
sweetened beverage, which is true for about
50% of added calories, but they had a lot of
other, had no desserts, they would already be at
around that 30 teaspoons a day and probably would not
have even realized it. So I just want to bring this
up to our point we don’t know yet how that sugar might
be impacting chronic pain. There is one study
in rats that showed that increase added sugar did
impact the excitatory nature of the vagal nerve in the
intestinal tract which then went on and changed pain
processing in the brain and had negative
impacts on the brain, but this is certainly
something we need to think about going forward
about whether or not it’s having an impact. Of course, these are
cross-sectional studies. What about causality? We have no idea. Does pain lead to
poor diet quality? Certainly people who are in pain
likely could have many reasons why they’re eating poor diets. Or does poor diet quality
lead to chronic pain or both? Here’s my thought. It’s not looking
good either way. Okay. In one direction, you
have increased mortality through cardiovascular
disease and cancer and depression, increased
depression. In the other one, you have
more pain and more severe and maybe you have both. So I just want to end with
the maybe some people’s view of increased diet quality here. I try to eat healthy, doctor, I never sprinkle
salt on ice cream. I only eat decaffeinated pizza
and my beer is 100% fat-free. Thank you for your attention. [ Applause ]

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