Gordon Saxe, MD: The Influence of Diet on Pain Management

Dr. Saxe discusses the role of nutrition in determining levels of inflammation and its potential in treating patients.

Diet may be a significant factor in pain management, with proper nutrition associated with improved levels of pain.

However, the implementation of dietary patterns may not be feasible in a typical physician visit or adaptable to all patient populations, who may need pharmacological treatment to address pain immediately.

In an interview with HCPLive®, Gordon Saxe, MD, University of California, San Diego, discussed the intricacies of dietary patterns in influencing pain management, particularly the relationship between omega-3 and omega-6 fats in determining level of inflammation.

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®: Could you give a brief summary of the presentation you gave this past weekend and any key highlights that are important to mention?

Saxe: The presentation looked at a few different topic areas having to do with the interface between diet, nutrition and pain management. One thing that I looked at was the mechanisms by which diet and nutrition can influence pain, whether pain intensity, pain perception, or so forth.

I delved into each of several representative mechanisms, and looked at the nuts and bolts about how diet influences the different pathways, and an overriding one being the process of inflammation. Then, I gave sort of dietary recommendations or suggestions that sort of flow out of that, for how one might manage a patient with pain, nutritionally.

HCPLive®: Could you talk about a specific diet that you find advantageous in reducing inflammation and kind of how that benefits pain management in the patient?

Saxe: I wouldn't speak so much about any specific diet as more of a dietary pattern. And it really needs to be individualized, there is no one size fits all, as far as I understand it. Although there are guiding principles that I think are somewhat universal.

One really important metric in looking at the relationship of diet and inflammation has to do with the the content of certain types of fats known as essential fats in the diet. Broadly speaking, we're talking about omega-6 fats and omega-6 fats. Omega-6 tends to promote the process of inflammation and omega-3 tends to be anti-inflammatory.

What matters in terms of the inflammatory potential of a diet is the ratio between the two. Often, doctors will prescribe omega-3 supplements for a range of conditions that may have an inflammatory component.

Typically, that's encapsulated fish oil, because coldwater fish are known to have a very high concentration of omega-3. In my view, what's even more important than supplementing is changing the foundation of the diet to rectify an imbalance between omega-6 and omega-3.

As best as we understand it, our Paleolithic ancestors had roughly a 1:1 ratio of omega-6 and omega-3 in their overall diet. By contrast, the standard American diet most people follow has about 20 parts of omega-6 to one part of omega-3.

The standard American diet is associated with a number of chronic inflammatory conditions. I believe that while it's not totally a matter of these fats in your diet, they do offer a good index of the inflammatory potential of the diet overall. We do need to have some omega-6 in our diet and we also need omega-3.

The process of inflammation is not inherently a bad thing. If we are injured, we suffer trauma. We cut ourselves and staff on the surface of the skin could get through the cut and cause an infection in the traumatized area. When that happens, a signal is sent.

Reflexively, blood cells get drawn to the site of the injury of the potential infection. They're carrying things like white blood cells to that site. In the process, as blood flows to that area, that area tends to become red, because you can kind of almost see the appearance of the blood under the skin.

As it fills in that area tends to swell up. It tends to press on nerve endings, and it causes pain. Often, there's a loss of function of the affected part. This is usually short lived, just a matter of days.

The problem occurs when the process becomes chronic, when there's a constant, low grade irritant that's triggering the inflammatory process. One of the things that causes low grade irritation is when we have a high intake of omega-6 relative to omega-3.

As a result, the Omega-6 goes into a biochemical pathway that occurs within every cell in the body called the arachidonic acid cascade. When it's omega-6 that feeds into that downstream, small molecules that are inflammatory get produced at the cellular level, and they tend to trigger inflammation.

On the other hand, when the precursor, the substrate, is much more omega-3, the arachidonic acid cascade responds by triggering a whole different arm that tends to produce downstream molecules that are anti-inflammatory. These instead act on cells in the body or act on tissues in the body. Not only is it anti-inflammatory, but it also tends to reduce platelet aggregation, it tends to help to dilate blood vessels.

We often talk very glowingly of Mediterranean diets, thought to be heart-friendly and thought to maybe be beneficial for other conditions.

Depending on what corner of the Mediterranean you're talking about, the diet is probably somewhere around between 4 parts of omega-6 to 1 part of omega-3. A lot less than the 20:1 ratio that the standard American diet and movement to a much healthier and more anti-inflammatory direction.

There’s evidence that when we do diet intervention studies, and we get the ratio in the diets people are consuming to below about 2.5 to 1, we start seeing clinical improvements in conditions like rheumatoid arthritis, or even a slowing of proliferation of cells in a condition like colorectal cancer.

Chronic inflammation is thought to be part and parcel of the process of a number of different chronic diseases that themselves can end up in pain.

HCPLive®: Are there any mechanisms that you think would need to be put into place for clinicians to be able to describe or give patients proper nutrition goals and the methods to get there?

Saxe: I think first and foremost, it's important for clinicians to have a sense of the full potential of what diet can do. When I was in medical school, I remember working with a faculty preceptor physician, who had me interview a patient in an exam room and report back to him.

The patient had hypercholesterolemia. The doctor asked me what I would recommend, and as I was trained in a previous life as a nutritional epidemiologist, of course, I thought, we need to help this patient change their diet.

I said the patient needed help changing their diet. The doctor said to me ‘Good point, but I already gave her the diet sheet and she didn't do anything. So I'm gonna put her on the statins.’ Of course, my thought was, you gave her the diet sheet, and you expected her to do anything. It takes a full court press to help patients to make the kinds of changes, often complex changes in their diet.

Not everybody, even under the best of circumstances, is going to do it. But, in selected patients, it can make a huge difference. There are a surprising number of folks who are really motivated to do that. They've already had so many medications with lots of side effects, that cost a lot of money. They’re sick and tired of it, and they want to do something that empowers themselves.

On the other hand, from the physician's perspective, this takes a lot of work. Their practices are not necessarily geared or set up to help patients make these changes. They're not easy changes for most people. Even for those of us who know better, we have to constantly remind ourselves about the importance of healthy food and proper nutrition.

But, the doctor also is fighting another headwind. Her or she doesn't have reimbursements, typically, to help offer this to patients. Their time is far more valuable diagnosing and treating diseases than it is counseling somebody and taking a lot of time in an area when it's not their forte.

We have the good fortune of a very aware patient population here in Southern California. It’s allowed us to put a team together of folks who can help.

But, it takes one-on-one counseling with a properly trained and smart dietician or nutritional counselor. It takes coaching to help people with a behavioral skill set that not every dietitian has.

It's important to help patients make the changes, there needs to be an effort at group support. There is both an economy and a kind of a magical force that happens when you bring people together in a group to help one another, it draws something out of each person to help other people that helps them in their own healing process.

When you have a lot of these elements in a sufficiently motivated population, it can work and it can even become self-sustaining, but it takes a lot of activation energy to get it to that point.