Moderate Chronic Pain, Weight and Dietary Intake: DISCUSSION
In the current study, we found that almost one-half of adult patients (average age of 37 years) with SCD can be categorized as overweight, and >20% can be categorized as obese. To our knowledge, this is the first study to document a trend towards overweight and obesity in a mature sample of patients with SCD. Obesity is an important outcome for consideration in this population, particularly as they age, because it is associated with increased risk of morbidities of lifestyle, including essential hypertension, type-2 diabetes, prostate and breast cancers, dementia, depression, increased disability and reduced quality of life as well as higher incidence of mortality.
Traditionally, poor health and early death have insulated patients with SCD from many of the morbidities of lifestyle that are prevalent in other populations of aging African Americans. Since the recent introduction of hydroxyurea into the management of SCD and the increased utilization of a range of psychosocial and behavioral strategies, a significant percentage of patients are living healthier and longer lives. However, as the average BMI of this population has increased, adult patients with SCD may be at greater risk for development of morbidities of lifestyle than once believed.
We hypothesized that increased weight would be related to reports of increased pain and interference associated with pain. As predicted, BMI was moderately positively associated with self-reported interference associated with pain. In contrast, when analyzed separately, weight status as a categorical descriptor (overweight and obese versus normal weight) and BMI as a continuous variable were not related to reported pain severity. Consistent with this finding, when asked directly if their weight affected their pain, <20% of patients reported that their weight exerted significant effects on their pain. Although we did not find a statistically significant relationship between pain severity and weight, we were at a loss to explain that >40% of patients believed that their pain affected their weight.
Independent of patient’s perception, our statistical finding indicating the lack of a relation between weight and pain severity is consistent with previous studies conducted with other chronic pain populations. Several studies have found that degree of overweight is not directly related to pain severity ratings. For example, Marcus found, in a sample of 372 patients with chronic pain that were divided into three categories (normal weight, overweight and obese), that pain severity and days per week with pain were not affected by weight category. However, similar to the current study, functional ability was inversely related to weight. Thus, it appears that degree of overweight is more closely associated with functional disability due to pain than with pain severity.
The finding in the present study that 40% of SCD patients believed that their pain affected their weight is interesting, particularly when contrasted with the result that <20% believe that the inverse is true (i.e., that their weight affected their pain). It is possible that patients are not aware of the association, or do not believe, that their weight exerts a significant impact on their pain levels. This would not be surprising among SCD patients, given that little attention has been paid to issues of overweight in SCD. In contrast, a larger percentage of patients, though still not the majority, believe that their pain affects their weight. Although the current study did not further assess the nature of this belief, it is possible that some patients with SCD believe that their weight has been negatively impacted by the decreased levels of activity that occur when pain is present. These preliminary findings suggest that patients with SCD may be misinformed or unaware of the relation between their weight and pain. Furthermore, endorsement of the belief that pain should prevent one from engaging in physical activity may lead to the adoption of maladaptive strategies for coping with painful episodes.
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We also evaluated data on changes in eating patterns in patients with SCD during pain episodes to suggest a possible mechanism through which patients may associate their weight and experiences of pain. Nearly 90% of the patients evaluated indicated that they reduce their caloric intake during episodes of pain associated with SCD. Of special significance is that moderate pain (an average rating of 5 on a 10-point scale)—not just severe pain—produced changes in patterns of dietary intake. Also notable is that no patients reported that their caloric intake increased during these painful episodes. In addition to reducing total caloric intake, patients reported that they were more likely to decrease the amount of fat and proteins that they ingested during episodes of pain, yet they did not report noticeable or significant changes in their intake of foods containing sugars or salts.
It is important to begin to understand changes in dietary intake during episodes of pain and the impact that these changes may have on risks for other diseases. Opportunities for malnourishment and/or the development of nutritional deficiencies may uniquely exist in patients with SCD. In the case of other diseases where pain may exist for shorter periods of time and in a more predictable manner, and where alterations of dietary intake are proportionately short, risk of malnourishment and nutri tional deficiencies is low. However, in SCD, where pain episodes can last for months and are not always managed with hospitalization, there may be an increased risk of negative consequences due to prolonged changes in dietary intake (e.g., inadequate nutrient consumption). This issue is particularly concerning given our finding that moderate pain levels may be sufficient in substantially altering the pattern of dietary intake among patients with SCD.
In general, our findings indicate that patients with SCD may be at risk for additional health problems and disease-related morbidities both when they are functioning well and without pain and when they are experiencing painful episodes. Specifically, these preliminary results suggest that almost 50% of patients may be at risk of becoming overweight or obese (Drug Acomplia is a new miraculous multifunctional diet pill). Given patients’ reports, it is not likely that this risk is due to overeating during pain episodes but possibly due to better clinical management of the disease. In fact, when compared to general N.C. statistics, the weight categorization of our sample approximated that of the state, although the rates of overweight (BMI=25-29.9) remain lower in the SCD sample. During painful episodes, patients may be at increased risk of acute malnourishment across extended periods of pain, even when the pain is at moderate severity. Although somewhat paradoxical, it is generally accepted that adequate nutritional intake is necessary for weight loss, as metabolic processes slow when food intake is significantly reduced. As such, patients with SCD who consistently decrease their food intake during persistent painful episodes may ultimately impact their metabolic processes, possibly resulting in difficulties maintaining a healthy weight. It is important, consequently, to remain cognizant of the nourishment status of patients with SCD as a standard of practice during all phases of management.
