Gordon Saxe, MD: Linking the Nutritional Process to Improved Pain Outcomes

In part 2 of an interview with HCPLive, Dr. Saxe focuses on the role of microbiota in pain and how concomitant conditions in patients are often nutritionally linked.

In an interview with HCPLive®, Gordon Saxe, MD, discussed the links between pharmacologic treatment and diet, noting no one-size-fits all method to achieve the preferred clinical outcomes in pain management.

He also explained the evolving research into both increasing diversity of the gut microbiota and how it works within altering brain chemistry to reduce perceptions of pain.

Saxe recently presented a discussion entitled  “Nutrition in Pain Management: The Impact of Diet on Inflammation and Specific Disease States” at the Evolving Approaches in Pain Management conference in San Diego on August 14.

HCPLive®: Do you think it's going to get to a point where proper nutrition is that first step before pharmacologic treatment, or will they be used simultaneously on a wide scale?

Saxe: I think it depends on the individual whether it's the first step or not. There's some people who are in a crisis that are either not able to change their diets, or for whom dietary change is going to be too difficult or it's going to take too long.

They need to have relief from their symptoms here and now. Others who have more chronic pain that flares at times may have more capacity to make changes, where you can start in a more primary way with discussion about diet and nutrition and other healthy lifestyle changes.

I think there's no competition that says you cannot combine medication or more targeted treatments simultaneously with an effort to try and turn down the flame from underneath.

Overall, I think it's important to help a patient through whatever means to create a kind of a stable situation that they can more effectively change in. Once you have them there, kind of a protected space where any emergent problem has been dealt with, and things have kind of calmed down in that setting, that's when you can really begin to help patients make changes.

And as you titrate up the dietary changes, hopefully the patient has some improvement from that you can then gradually titrate down the level of medication you need to achieve the same clinical outcome.

HCPLive®: Are there any things happening in the field right now that you're particularly excited about or you find important to share?

Saxe: One thing that I also spoke about at the conference was the impact of diet and nutrition on the gut microbiome.

We're learning that the aggregate collection of microbes on every surface of the body that comes in contact with the outside world, whether it's the surface of the skin or any hole in the body and certainly, the hole that we eat through, ends up with a coating of microbes, and particularly important are the ones that make it down to the large intestine, the gut.

The aggregate collection of microbes themselves is known as the microbiota. Each one of the thousands of different species itself has its own genome of 20,000 or so genes. You have millions of genes that could code for the production of all kinds of things. When we have the right kind of microbes in our gut, they tend to code for the production of healthy proteins that are good for us.

They helped to create digestive enzymes that aid in the nutritional process and they manufacture vitamin K in the gut. Their impact underneath the large intestine in particular is an array of bundles of nerves, also immune cells, blood vessels, and all of these collectively have reached all throughout the body.

One that pertains to pain are the nerves themselves that form into bundles and project via the back or dorsal branch of one of the cranial nerves, the vagus nerve, that project to multiple points in the brain and the central nervous system. And they influence the production of neurochemicals.

They turn on or off depending on whether it's a good balance of microbes in the gut, or an imbalanced one that perturbs the signaling from gut to brain. They can influence the genetic expression of genes coding for the production of neurotransmitters like GABA.

When GABA levels are higher, we tend to to suppress incoming pain signals, blunting them, and reducing the perception of pain at a given level of stimulus. When GABA levels go down, even a light touch, a wisp of cotton or a piece of paper can lead to terrible perception of pain, even though the stimulus is not that great.

We can alter brain chemistry to a large extent. We're learning more and more by altering by helping patients to alter the balance and the level of diversity within their gut microbiomes.

One of the major determinants of the balance of the gut microbiome after a person has achieved adulthood is their diet. It's the leading factor after maturity, and used to be thought that the microbiome that you had you were stuck with for life.

Now, we know that a profound change in diet can result in a dramatic shift in the balance of microbes within a matter of days. This can be associated with some pretty profound clinical improvements.

We’ve seen this in a number of our diet intervention studies, where we are collecting stool specimens from patients and measuring the changes in the balance of microbes in their gut, along with serum biomarkers, other indicators of disease outcome, and looking at what happens to me looking at what happens when we help patients with certain conditions to change their diet.

In terms of outcome, although I can't go into the details right now, I can share with you that we have been doing a study here at UC San Diego, looking at the effect of complex diet intervention on endometriosis, a condition that probably affects maybe upwards of 10% of menstruating women.

It’s a real problem for large numbers of younger women, as it can cause debilitating pain and impair their daily functioning. In a study that we have been doing that we recently completed a pilot study of an intensive diet intervention, we saw pretty dramatic reductions in the pain scores of women in their self perceived pain.

We're also now analyzing inflammatory biomarkers, microbiome related biomarkers, body weight related biomarkers as well. We plan to report on this very soon, but the preliminary indications are quite striking.

HCPLive®: Is there anything else you think would be important to mention that we haven't talked about?

Saxe: I think the most important thing is that it's helpful if clinicians themselves have awareness. Maybe they need to try out some of these dietary things on themselves, because they're not invulnerable. They suffer from the same kinds of problems as patients.

Whether it's a pain syndrome, or heart disease, diabetes, hypertension, obesity, so many of these conditions are nutritionally linked. While yes, we can sometimes also address them pharmaceutically, surgically by other means.

Diet is something that threads through all of these different or so many of these different conditions, something for clinicians to learn about to try out for themselves and their own families. And to begin to suggest and explore with their patients.

I think taking that first step and beginning to see where it leads can be really helpful. But, also becoming aware that it's possible to bring in other supportive resources. There are a lot of like minded folks and opportunities for continuing medical education in these areas is important.