SEATTLE—Nutritional strategies can make a world of difference for patients with chronic pain and inflammation problems like arthritis, low back pain, and fibromyalgia, said Benjamin Kligler, MD, at an Integrative Pain Management symposium sponsored by Columbia University’s Rosenthal Center for Complementary and Alternative Medicine.

Elimination diets, reduction of trans-fats, and supplementation with omega-3 fatty acids, glucosamine/chondroitin, and herbs like rosemary and ginger, represent “long-term preventive background strategies,” said Dr. Kligler, a family physician who is co-director of the Continuum Center for Health & Healing at Beth Israel Medical Center, New York. “These things don’t produce relief in a minute, an hour or even a day or two. They provide gradual effects over time.”

Dietary changes, nutritional supplements and botanicals can be combined to reduce triggers of inflammation, shift cytokine production from pro-inflammatory to anti-inflammatory patterns, and increase clearance of free-radicals that contribute to inflammation. In many cases, they can help patients break their reliance on COX-2 inhibitors, steroids, NSAIDs and other side-effect laden pharmaceutical pain relievers. Dr. Kligler, author of Integrative Medicine: Principles for Practice (McGraw-Hill), reviewed treatments and dietary interventions he has found effective in clinical practice.

Food Sensitivities & the Elimination Diet

Conventional physicians have tended to side-step the issue of food allergies as triggers for chronic pain problems, in large part because these are not “classical” IgE-mediated allergic reactions, but rather, IgG-mediated sensitivities. Consequently, they are not detected by standard allergy testing methods. But there is a growing body of data to support the concept that food sensitivities underlie problems like rheumatoid arthritis, irritable bowel and fibromyalgia.

Dr. Kligler has found that in practice many chronic pain patients have sensitivities to one or more common foods such as wheat, dairy, refined sugar, corn, soy, citrus, shellfish, nuts and seeds, yeast and coffee. Identification of trigger foods, and elimination or at least minimization of their consumption, can go a long way in controlling chronic pain problems.

Unfortunately, the only truly definitive method for identifying food sensitivities is an elimination diet. Basically, this means that the patient should eliminate all of the aforementioned foods from their diets for 2–4 weeks. They should restrict themselves to a very simple diet of rice, non-citrus fruits and vegetables, fish and lamb (if they are meat-eaters). “If there’s significant improvement in the patient’s pain symptoms, you can safely conclude that there is a food sensitivity.”

The next step is to gradually add back potential trigger-foods, one every 2–5 days, and have the patient carefully track any return of symptoms. “Dairy is a very common trigger, as is soy. You might find one, or you might find five.”

An elimination diet takes considerable motivation from a patient, but it is effort well expended because identification and elimination of a food to which the patient is sensitive can provide marked pain relief over time. The other positive aspect of this approach is that if, after 4 weeks, there is no change in the patient’s symptom pattern, one can rule out food sensitivity as a root mechanism, and the patient won’t have to make any long-term dietary changes.

Other Dietary Strategies

A host of diets have been proposed as remedies for chronic pain. Data to support these approaches is variable, but Dr. Kligler noted that one could make a fairly strong scientific case for reduction of meat and dairy.

Finnish investigators conducted a small, open trial comparing 18 fibromyalgia patients on a 3-month vegan (meat and dairy-free) diet with 15 controls who continued to eat meat and dairy foods. Those on the vegan diet had improved pain scores, reduced joint stiffness, and better sleep quality (Kaartinen K, et al. Scan J Rheum 2000; 29(5): 308–313).

Researchers at the University of Oslo, Norway, reported a similar finding in a cohort of 53 patients with rheumatoid arthritis (RA) who followed a vegan diet for two years. The patients had significant improvements on all self-assessment scales for pain, morning stiffness, number of tender or swollen joints, and grip strength. Interestingly, though, there were no meaningful changes in RA-related lab values (Kjeldsen-Kragh J, et al. Clin Rheum 1994; 13: 475–482).

Fasting may also benefit patients with RA. Swedish investigators reported measurable decreases in disease activity, neutrophilic release of lysozyme, aggregation of polymorphonuclear leukocytes, and release of leukotriene B4 in a cohort of 14 RA patients after a week-long total fast (Hafstrom I, et al. Arthritis Rheum 1988; 31(5): 585–592).

There is some recent evidence that insulin-resistance and diets rich in highly glycemic foods may contribute to chronic inflammation. Researchers from the Department of Preventive Medicine at Harvard studied the eating habits of 244 healthy women and found a strong, statistically significant association between glycemic load and plasma levels of c-reactive protein. This was independent of risk for ischemic heart disease. The authors concluded that high intake of rapidly digested carbohydrates exacerbates pro-inflammatory mechanisms (Liu S, et al. Amer J Nutr 2002; 75(3): 492–498).

Though conclusive data are not yet available, it makes good sense in principle for patients who experience chronic inflammatory pain to reduce their intake of pro-inflammatory trans-fats, as well as dairy, coffee, refined sugar and other foods associated with inflammation. Dr. Kligler acknowledged that, “nutritional maneuvers require a lot of patient motivation and empowerment. You have to let them know that the diet may eventually fall apart, that they will very likely ‘stray,’ and that this is not a sin or character flaw. They just have to get back on the wagon and keep up with what really works best for them.”

Omega-3 Fatty Acids

Supplementation with omega-3 fatty acids is an essential part of any dietary strategy for reducing pain and inflammation. Increasing the intake of omega-3’s relative to omega-6 fatty acids will down-regulate conversion of arachadonic acid into inflammatory cytokines like prostaglandin E2, while increasing production of anti-inflammatory signals like prostaglandin E3 and leukotriene B5. A number of studies over the last decade have shown that this can greatly benefit patients with various forms of arthritis, ulcerative colitis and menstrual pain.

Belgian researchers randomized a cohort of 90 RA patients to 2.6 grams of omega-3s per day, 2.3 grams of omega-3s plus 3 grams of olive oil, or 6 grams of olive oil, for a period of 12 months. They observed a significant reduction in symptoms as well as reduced use of pain medications only in those on the high-dose omega-3 regimen. Moreover, this benefit was sustained over the entire 12-month period (Geusens P, et al. Arthritis Rheum 1994; 37(6): 824–829).

Though most people think of fish oils as the primary source of omega-3s, gamma-linolenic acid (GLA) from borage or evening primrose oil, is also effective in reducing arthritic pain. A study of 37 RA patients randomized to 24 weeks’ treatment with 1.4 grams per day of GLA or placebo showed a 36% reduction in number of tender joints, a 45% reduction in joint pain scores, a 28% reduction in number of swollen joints, and a 41% reduction in swollen joint scores among those taking GLA (Leventhal LJ, et al. Ann Int Med 1993; 119: 867–873).

More recently, British investigators randomized 49 RA patients to daily treatment with inert oils, 540 mg GLA, or 240 mg eicosapentaenoic acid (EPA) plus GLA. All patients were treated for 12 months, and then switched to placebo oil for an additional 3 months. They found significant reductions in use of NSAIDS, as well as improvements in pain symptoms in the treated groups only. The symptoms returned rapidly once these patients were switched to placebo (Belch JFF, et al. Ann Rheum Dis 1998; 47(2): 96–104).

A very recent study further bolsters the case for omega-3 supplementation. Joseph Maroon, MD, of the Department of Neurosurgery, University of Pittsburgh, assessed 250 patients with non-surgical neck or back pain, taking either 1,200 mg or 2,400 mg daily doses of a mixed omega-3 combination (Nordic Naturals’ high concentration EFA formula, containing 900 mg EPA, 200 mg DHA) for an average of 75 days. Based on a detailed questionnaire, he found that 60% had improvements in overall pain and joint pain symptoms, 88% said they would continue to take the omega-3s, and 59% were able to discontinue the use of prescription pain medications. Dr. Maroon presented the data, which has not yet been published, in April at the annual meeting of the American Association of Neurological Surgeons.

Rheumatoid Arthritis & Coronary Disease

One of the most compelling motivations for using nutritional approaches to reduce inflammation in RA patients comes from a Mayo Clinic population-based case-control study showing alarming increases in coronary heart disease in people with RA. The investigators followed 603 adult RA patients and an equal number of age and gender-matched controls for a mean of 13.5 years. They found that the RA group were two times more likely to have unrecognized MI and also twice as likely to die of sudden cardiac deaths.

What is most surprising is that during the two-year period immediately prior to being diagnosed with RA, these patients were three times more likely to be hospitalized for acute MI and almost six times more likely to have unrecognized MI. RA patients were 40% less likely to have symptoms of angina. The data strongly suggest that some sort of inflammatory mechanism predisposes RA patients to CVD, and that this trait predates the joint disease. The Mayo researchers said that the elevated risk cannot be explained by increased incidence of traditional CHD risk factors, or by rheumatoid medication side-effects (Maradit-Kremers H, et al. Arth Rheum 2005; 52(2): 401–411).

Given the well-documented cardiovascular benefits associated with omega-3’s, supplementation in patients with RA is something of a no-brainer, said Dr. Kligler. “There are so many other health benefits that even if they don’t work for reducing pain, you’ll still be doing your patients a favor.” He added, “There is almost no down side to using omega-3 supplements, beyond the fishy burps that some patients experience.”

Glucosamine Sulfate for Osteoarthritis

The science supporting the efficacy of glucosamine sulfate supplements for patients with osteoarthritis is very strong, said Dr. Kligler. “There are studies showing that glucosamine is equivalent to NSAIDs. It works and there’s no doubt about it. If you haven’t tried it with your osteoarthritis (OA) patients, I highly recommend it.”

German investigators randomized 200 patients with OA of the knee to glucosamine sulfate, 500 mg, thrice daily or ibuprofen, 400 mg thrice daily, for a total of 4 weeks, and found the two treatments to be equivalent in terms of reducing pain symptoms (Muller-Fassbender H, et al. Osteoarthr Cartil 1994; 2(1): 61–69).

This substance has direct effects in sparing the cartilage in the joint capsules. A study sponsored by the World Health Organization involved 2,000 OA patients who took 1,500 mg of glucosamine sulfate or placebo daily for 3 years. Those on placebo lost an average of 0.33 mm in cartilage thickness over the 3-year period, while those on glucosamine lost a mean of only 0.06 mm. Symptom scores correlated inversely with cartilage loss: they were greater in the placebo cohort and significantly lower in those taking the supplement (Reginster JY, et al. Lancet 2001; 357: 251–256).

Dr. Kligler underscored that glucosamine is not a quick-fix, immediate-relief therapy. It requires 2–6 weeks of daily supplementation to provide optimum benefit, and patients should be informed of this. He added that there’s no evidence that pushing the daily dose beyond 1,500 mg (500 mg thrice daily) will increase the disease modifying effects.

Safety-wise, glucosamine sulfate is a very benign substance for the vast majority of patients. “Be careful with patients who are sensitive to shellfish (glucosamine is prepared from marine chitin sources), and also be aware that it can increase blood sugar, so be careful with diabetics or insulin resistant people. Other than that, it is very safe.”