Many serious conditions and diseases, including hyperlipidemia, obesity, congestive heart failure, and renal failure, have their own recommended diet. Considerable scientific information and clinical observation have accumulated in recent years that chronic pain, particularly the debilitating, severe form that requires opioid treatment, needs a “chronic pain” diet.¹⁻⁶ To date, however, no chronic pain diet has been officially recommended. Therefore, the goal of this article is to provide pain practitioners with a pain diet.
The fundamental principle of the diet is that patients with chronic pain need a high-protein–intake diet with avoidance of carbohydrate (sugars and starches)-induced episodes of hypoglycemia and weight gain. It also is intended to promote strength, movement, energy, and mental function. The dietary supplements also recommended are intended to assist regeneration of tissue and prevent osteopenia and osteoporosis.
Background
Chronic, severe pain causes excess adrenal secretion of cortisol and catecholamine, which makes glucose serum levels unstable.⁷ Levels may vary from hyper- to hypoglycemia. Pituitary–adrenal exhaustion may occur if severe pain goes uncontrolled for an extended period of time. The net endocrine–nutrition effect of uncontrolled pain is loss of appetite, deficient protein intake, and food intake consisting almost solely of carbohydrates (sugars and starches). This catabolic state will manifest clinically as weight loss, muscle wasting, weakness, and poor mentation (see Table 1).
Opioid treatment also has a profound effect on the endocrine–nutrition system, compounding the necessity of a pain diet.¹⁻⁴ Patients on opioids commonly gain weight and prefer sweet foods (see Table 2). Weight gain may be profound, with some patients doubling their weight within a few years. Opioid use may cause blood sugar levels to be very unstable and may cause hypoglycemia.⁵⁻⁷ Opioids also cause a “sugar desire effect” on opioid receptors.⁸˒⁹ Consequently, the combination of severe chronic pain and opioid treatment can cause deranged glucose metabolism in patients and a potent desire to ingest primarily sugars and starches, with little protein or fat intake.
Patient Observations
Clinical observations of patients with chronic pain who require opioid treatment support the scientific research and the adverse effects of pain and opioids on the endocrine–nutrition systems.¹⁻⁹ In order to evaluate a patient’s nutritional status, I use a 72-hour “Food and Drink Recall Diary” form with new patients with chronic pain (see Table 3). Over the 3-day period just prior to admission, new patients almost always report a gross deficiency of protein intake. Protein foods, defined here as food with more than 50% protein by weight, such as fish, beef, poultry, lamb, eggs, or cottage cheese, are rarely eaten. Green vegetables such as beans, broccoli, or brussels sprouts, which contain about 30% protein, also are conspicuously absent from their diet. About the only protein some patients ingest is milk.
This recall form is highly recommended because it is not designed to calculate calories, but simply to determine if the patient with pain is eating any protein. Prior to good pain control, most patients report their appetites to be so poor that they seldom eat much of anything except sweets and some starches. Physical examination of these patients often shows loss of muscle mass with weakness, so much so that listing “malnutrition” is warranted as a secondary diagnosis in the patient’s chart.
It is highly suggested that pain practitioners take a dietary history for protein intake and examine the patient for muscle loss and weakness. Patients with pain may drink large amounts of sugar drinks and milk. Although milk is about one-third protein, the remaining two-thirds are about evenly divided between fats and carbohydrates.
Some patients with pain give a history that about 2 hours after eating a carbohydrate load, such as a doughnut, bagel, or glass of fruit juice, their pain will flare. Although I’ve never tested blood sugar levels during these reported flares, I highly suspect that hypoglycemia causes pain flares in some patients. A major element of the diet recommended here is stabilization of blood sugars.
Why Is Protein So Critical?
There are four sound, theoretical reasons why a chronic pain diet should be based on high-protein intake.
1. Endogenous Pain Relievers Are Protein Derivatives
In the intestine, all proteins break down into their component parts, which include about two dozen different amino acids. There are eight essential amino acids that the body cannot make, and therefore must be supplied through one’s diet. In alphabetical order, these are isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine. With adequate nutrition, the body can make the other amino acids, with the possible exception of carnitine. Amino acids enter the blood from the intestine and travel to locations in the liver, glands, and brain, where they are building blocks for compounds critical to pain relief. These include endorphin, dopamine, serotonin, and γ-aminobutyric acid (GABA). Insulin and thyroid hormones are derived from amino acids.
The universal complaint of weakness by patients with severe pain may have many causes, but a lack of protein has to be one of them. Even the receptors to which pain-modulating neurotransmitters (endorphin, serotonin, and GABA) attach are protein moieties. Although no one knows how much protein a patient with pain must take in to provide enough amino acid substrate for the production of these pain-controlling compounds, my dietary histories intuitively tell me it’s often not enough.
2. Protein Builds Muscle-Cartilage
A number of amino acids are required to build muscle. The amino acid proline is the major building block of collegen, essential for the development of cartilage and intervertebral discs.
3. Protein Activates Glucagon
Glucagon is secreted by the liver in response to protein ingestion. Glucagon increases blood glucose levels, and is the only hormone that blocks glucose storage as fat. Eating protein with every meal and every time sugar and starches are eaten will prevent a rapid rise in insulin, storage of any excess glucose as fat, and hypoglycemia that results in carbohydrate cravings and possible pain flares.
4. Protein Decreases Inflammation
Many foods that contain protein, such as fish and green vegetables, contain anti-inflammatory agents.
The Diet
The major dietary recommendation for patients with chronic pain is to eat protein foods with each meal and to not eat or drink carbohydrates without eating protein at the same time. To assist with dietary counseling, I provide a one-page handout (see Table 4). I recommend only diet drinks in an effort to restrict carbohydrates and prevent hypoglycemia and weight gain. Juice, milk, regular sodas, and energy drinks are prohibited, as they are loaded with carbohydrates and may lead to hypoglycemia.
In contrast to a lot of other medical diets, I allow sugar-free, caffeinated drinks. It is well known that caffeine raises brain dopamine levels, which gives a little extra pain relief. Salt is restricted, because opioids may cause edema, and extra edema around pain sites may aggravate pain. Unless weight is normal, I restrict milk, as it is quite fattening.
Hyperlipidemia
High cholesterol, lipids, and glucose are almost universal in patients with uncontrolled pain because of excess cortisol secretion from the adrenal gland. Good pain control will usually lower high serum lipid and glucose levels. Adequate intake of protein with carbohydrate restriction also will help to control lipid and glucose levels. I believe that good pain control and a high-protein diet should be achieved before starting any anticholesterol medications.
Weight and Obesity
Many patients with pain have pain sites in the spine, hips, knees, and feet that may be aggravated by excess weight. Other patients with pain, such as those with fibromyalgia, headaches, or some neuropathic pain, may not be affected by excess weight. The diet recommended here is, with some exceptions, akin to the low-carbohydrate (Atkins) diet that is used in many weight control programs. It does not eliminate carbohydrates but attempts to restrict them by emphasizing protein intake.
The problem with reducing weight in patients with chronic pain is multifaceted. Chances are, patients can’t move or exercise enough to lose much weight. Medication that will relieve pain, whether an opioid, sedative, muscle relaxant, or antidepressant, may suppress the body’s metabolism and cause weight gain. Anorexiants may be of little assistance because the patient with pain may be eating very little. If the protein diet recommended here doesn’t cause weight loss, I recommend adding a stimulant such as phentermine.
Dietary Supplements
Certain dietary supplements may enhance any diet recommended for patients with pain. My pain diet recommends a daily vitamin–mineral preparation, an osteoporosis prevention compound (vitamin D, magnesium, and calcium), regular vitamin B12, and protein supplements.
There are many amino acid powders, bars, and drinks marketed to athletes and bodybuilders. They make excellent supplements for patients with chronic pain. I like to use protein supplements simply to ensure that there is enough amino acid substrate in the body to synthesize the neurotransmitters, hormones, muscle, and cartilage required for pain control and regeneration of tissue.
Follow-up Critical
One-time dietary counseling alone won’t change nutritional habits. It is highly recommended that periodic nutrition follow-up be done. At each clinic visit, I use a form that asks patients what protein they have eaten in the 2 days just prior to their clinic visit and to list their dietary supplements. If these inquiries are in writing and part of a routine follow-up clinic visit, patients are constantly reminded that diet and nutrition are important.
Summary
A high-protein diet combined with restriction of carbohydrate and salt is recommended for patients with chronic pain. Protein contains the amino acids that are critical for many pain control functions, including formation of many neurotransmitters, hormones, muscle, and cartilage. Other components of a chronic pain diet ideally should contain select dietary supplements that help reduce inflammation, control weight, prevent osteopenia and osteoporosis, and regenerate nerve cells. Practitioners are urged to take a dietary history because the majority of chronic pain patients are woefully deficient in protein intake. Clearly, dietary counseling must be a component of chronic pain care.