Diet, weight and being in pain

Lifestyle changes is not probably a topic that most doctors discuss with their patients in pain. One of the great physicians of the early 1900s William Osler once said ”The good physician treats the disease; the great physician treats the patient who has the disease.” The best way to treat a disease in my opinion is to treat the whole patient with the biopsychosocial approach : see my previous post on slow medicine vs fast medicine. Most diseases occur because of the interaction between genes, lifestyle and environment.

Diet is an essential part of our lifestyles. Currently, the diet of most people in the US is contributing to many diseases. Below is a graph with the prevalence of diabetes in US:

People can argue which food increased the diabetes prevalence, but I think it is pretty clear that the diet is the cause. Definitely, this increase is not due to purely genetic factors. Our bodies are very efficient in using energy and our food is too high in calories. It is quite remarkable that nowadays we pay more for food with less calories in order to eat healthy. Our ancestors would be incredibly puzzled.

Interestingly enough many patients I see in my pain clinic do not make a connection between their lifestyle and their pain. Many of them blame osteoarthritis (inflammation) in their joints for their pain. Diet has a very important role for inflammation in our bodies and the standard american diet rich in processed food and sugar is one of the worst. Some diets shown to help with inflammation and prevention of disease are DASH and Mediteranean diet. A few institutions recommend antiinflammatory diets: Harvard link, Cleveland clinic link and University of Wisconsin pdf file. Besides inflammation there are studies showing that food rich in excitatory molecules aggravates chronic pain. One example is monosodium glutamate (MSG) with studies showing that MSG is not good for some fibromyalgia patients (an overview here). A review of the inflammation and chronic pain is on the pain science website.

In addition to the diet obesity creates a state of inflammation in the body that seems to induce diabetes, heart disease, cancer (one scientific paper) and probably pain too. This is a decent review of the relationship between obesity and chronic pain: practical pain management link. One indirect link between obesity and pain is diabetes which damages nerves and creates neuropathies. Obesity also creates mechanical stress and increases the risk of damage in the weight bearing joints. Everybody who is overweight/obese can try the following experiment: get a backpack, put 30 pounds of weight in it and walk around….this is how your 30 pound lighter body feels every day.

If you need motivation to change your diet you should watch a few lectures by Robert Lustig: http://www.robertlustig.com/. If you are interested in biochemistry, metabolism and general science Peter Attia might be a place to start: https://peterattiamd.com/. Serious research about lifestyle changes and various diseases was published in prestigious journals over many years by Dean Ornish who promotes healthy diet, stress reduction, social support and moderate exercise. Obviously diet and lifestyle changes cannot fix everything and that is why we have modern medicine to help. But if there is a choice between medications, surgeries and lifestyle changes I am not sure why somebody would choose the first two options.

The tight integration of the immune and nervous systems

Years ago, in the medical school I learned about various parts/systems in our body. But nobody spent much time in putting everything together. Nowadays I think the situation is still the same and most doctors end up looking at our bodies as a piece here and there. Of course having so many specialized doctors does not help the integration cause.

Over the last year I spent some time reading about the interactions between the immune system and the nervous systems. Depending where we draw the line I would argue that the immune system and the nervous system are basically one thing. The immune system can be seen as part of the sensory system with a role to inform the brain about potential bacteria/viruses present around the body. Nervous system also modulates the immune system. An interesting presentation by Kevin Tracey (TEDMED talk) describes how the vagus nerve changes the immune response. Another lecture by him goes even in more details: the academy of medical sciences talk. Currently there are efforts to use vagus nerve stimulation to treat autoimmune diseases like Crohn’s disease and rheumatoid arthritis (one article here).

The central nervous system (brain and spinal cord) has a significant amount of immune cells in the form of microglia. It is estimated that microglia are 10-15% of all glial cells in the brain. Microglia are tightly integrated with neurons and have a role in the maintenance and regulation of the synapses between neurons. Things can go wrong. There are theories that some forms of depression are caused by inflammation. Charles Raison is one physician researcher who is working on depression and immunity (this interview with Rhonda Patrick is really good). The other day I read an article in the New York Times where cases of schizophrenia seemed to be related to the immune system. In this article one patient developed what appeared to be schizophrenia, then developed leukemia and had stem cell transplant. His schizophrenia resolved after the stem cell transplant. Another patient had leukemia and got stem cell transplant from his brother who had schizophrenia. Strangely enough this second patient developed schizophrenia himself.

The connection between the immune system and the nervous system has been used for thousands of years in yoga and practices of breathing exercises. One recent version is the Wim Hof method which is a combination of cold exposure, meditation and breathing exercises. For a perspective about Wim Hof, the man, this is a good documentary by Vice. Luckily some researchers got involved and they showed that the practitioners of Wim Hof method had a different response when they were injected with Escherichia coli endotoxin. You can read the article published in PNAS for free: here. Anecdotal evidence from the followers of Wim Hof method suggests an improvement of the autoimmune diseases. There is a book by Scott Carney that discusses more on this topic: link here.

This post is just a little introduction on the this topic. My interest is in chronic pain and I think inflammation and pain create a vicious cycle that maintains both of them. We have to start looking at the bigger picture when we treat complex diseases like chronic pain.

Slow medicine vs fast medicine

We live in a fast-paced society. It seems that new technological advances happen every day. We see commercials for better cars, new TV sets, super fast phones (which are pretty much computers in our pockets). I think some of the expectations are transferring to the medical care. Patients expect a fast fix for most diseases. They ask: doctor, do you have a pill to fix this or that? Or an injection, or maybe a surgery?

I think it is worth trying to look at the bigger picture. The time scale in biology is very different than in technology. Little changes happen in our bodies every second and some times these little changes accumulate over many years to cause a disease. Furthermore, we do not live suspended in a vacuum. We interact with our environment; we are part of the environment. During history different trends in medicine tried to make sense of the bigger picture. In 1960 George Engel published “A Unified Concept of Health and Disease”, a paper that I would recommend to everybody (it was recommended to me in a book by Lorimer Moseley and David Butler). George Engel promoted the biopsychoscial model of disease. He criticized the medical practice at that time, medical practice which is still the same today. A few key paragraphs from his paper:

“To be able to think of disease as an entity, separate from man and caused by an identifiable substance, apparently has great appeal to the human mind. Perhaps the persistence of such views in medicine reflects the operation of psychological processes to protect the physician from the emotional implications of the material with which he deals.”

“Patients, certainly, regardless of their level of education and sophistication, prefer to blame their illness on something they "caught" or ate or that happened to them and to think of disease as something apart.”

“A disease, then, has substantive qualities, and the patient can be cured if the diseased ("bad") part is removed. That this often proves to be the case, as attested to by the successes of surgery, is actually not evidence for the validity of such a point of view”

In more recent times the trendy terms are mind-body medicine and integrative medicine. I would argue that both of these new terms are trying to accomplish the same thing as the biopsychosocial model, take the patient as a whole person interacting with the environment. Diseases are caused by a combination of genetic factors, lifestyle and environment. At this point we cannot control most genetic factors, but we have the power to change the lifestyle and the environment. However, changes come through education and with effort. Last national program with meaningful results was the campaign against smoking. Since then other issues took over, one of the most important being the obesity.

Once a disease develops I think it is worth looking again at the cause of the disease and work very hard to change the contributing factors. Also we have to be cognizant that it will take time to reverse biological processes. Usually a disease does not develop overnight and the solution takes time too. This is what I would call slow medicine. Of course, there are medications we can give to patients in the meantime, but the medications should be only a short term solution for most conditions. Medications have many predictable and unpredictable side effects: see my blog post (Side effects of medications). Small incremental positive changes for long term benefit are not that appealing in the current culture. I think we really need a change in culture. In my case I treat chronic pain conditions. I have many patients who come to me and say they had pain for over 10 years. At this point their whole nervous system is changed, their social lives are different, their psychological status is different. One medication or injection is not going to change everything. I tell them that there are things I can do for them (e.g medications, procedures, referral to physical therapy/psychology) and there are things they can do for themselves (e.g. lifestyle changes, weight loss, healthy diet, quit smoking, participate in physical therapy/psychology). We will work together as a team and manage their pain.

The other type of medicine I would call fast medicine. This is very dramatic and appealing to the doctors/patients/general public. Fast medicine includes surgeries, treatment of cancer, curing of possibly deadly infectious diseases. There is definitely a place for fast medicine, we need it. I love fast medicine myself. I am an anesthesiologist and enjoy practicing fast medicine in the OR, fixing things fast. It is very rewarding. Every now and then I am blown away by what fast medicine can accomplish. Recently I read this article in the journal Nature: “Regeneration of the entire human epidermis using transgenic stem cells” (Nature volume 551, pages 327–332, for a general public version of the story here). Basically they had this kid with a genetic disease (Junctional epidermolysis bullosa) that involves the skin (superficial layer called epidermis) and mucosa. His skin had a lot of wounds (60% of his epidermis was lost). They took biopsies from his skin, engineered his skin stem cells to get rid of the genetic mutation, grew epidermis in the lab and transplanted it on the kid. In the end, they were successful in replacing 98% of his skin. It felt like reading a Sci-Fi short novel, truly remarkable stuff. But in the big picture if they stop here it will still be a failure. First, they did not fix his mucosa. Then, the kid likely has already tremendous psychological baggage and that is likely true about his parents. His social situation is also different after living with this disease.

In the big picture we have to understand when to use fast medicine approaches and when to use slow medicine approaches. I would argue that fast medicine needs slow medicine to take over afterwards and look at what caused the situation to occur in the first place, reverse what can be reversed and take care of the long term consequences.