Moderate Chronic Pain, Weight and Dietary Intake
INTRODUCTION
Sickle cell disease (SCD) is an inherited blood disorder that diminishes the capacity of red blood cells to carry oxygen. One in 375 African Americans in the United States has SCD. SCD also affects individuals of Hispanic, Native American, East Indian, Greek, Italian and Eastern Asian ancestry. The characteristic marker of this disease involves the sickling of blood cells, which occurs when deoxygenated hemoglobin molecules distort the normal shape of red blood cells. These cells can constrict blood flow, causing disruptions in the supply of oxygen to tissues and organs and inhibiting the elimination of carbon dioxide. This vasoocclu-sive process results in tissue and organ damage as well as other SCD-related complications. Specifically, sustained vasoocclusion can produce systems-level damage and other medical complications, including but not limited to delayed growth and sexual maturation, generally poor health, acute and chronic pulmonary dysfunction, stroke, aseptic necrosis of the hip and/or shoulders, sickle cell retinopathy, dermal ulcers, cognitive impairments secondary to chronic hypoxia and early-onset cerebral vascular events (CVEs), severe and debilitating pain and low body weight.
Given these complications, patients with SCD have historically experienced extended periods of hospitalization, high healthcare utilization rates, frequent emergency room visits, early exposure to narcotics, and psychosocial dysfunctions. They also experience impaired quality of life (QOL) to include reduced physical activity and early mortality. Standard treatments for SCD-related complications have included pharmacologic and psychotherapeutic management of painful crises and efforts to increase caloric intake and weight gain to counterbalance the effects of poor nutrition and low body weight.
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Until recently, patients with SCD typically only lived into their 30s. Today, we have progressed such that patients with SCD are living longer and with less disease-related morbidities due, in part, to drugs like hydroxyurea. An antimetabolite, hydroxyurea was approved in 1967 as an anticancer drug and was used in the treatment of a variety of hematological diseases, such as clonal myeloproliferative disorders (MPDs) and malignant solid tumors. As one of the best indices of recent pharmacologic, medical and psychosocial progress, Piatt et al., in a sample of 3,764 patients with SCD, reported a median age at death of 42 years for males and 48 years for females with sickle cell anemia, and 60 years for males and 68 years for females with hemoglobin SC disease. Although a significant relative improvement, these mortality rates remain nearly 30 years below nondis-eased controls (70 and 75, respectively).
This relative increase in longevity, possibly representative of better-managed disease-related morbidities, better nutrition and less frequent pain crises, has yielded an expected increase in weight and general physical functioning as well as decreased disability. However, increased longevity has also yielded a sudden need to understand, manage and reduce unanticipated morbidities of lifestyle—such as essential hypertension, diabetes and obesity—diseases that are common to aging cohorts of African Americans.
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Regarding caloric intake and eating patterns, the historical thinking among many treating clinicians has been that caloric intake is reduced among patients with SCD during painful crises, and this reduction is balanced by weight gains that are the result of better pain management. More specifically, reduced pain results in reduced disability and ultimately an increased probability of activity and better nutrition. However, little, if any, research has been done to determine the accuracy of these clinical assumptions for patients with SCD.
A small body of literature suggests an association between increased stress levels and reductions in macronutrient intake. Similarly, a limited number of studies have indicated that reduced stress levels (pain can be considered a specific type of stressor) are associated with improved dietary choices and nutritional status. One study found that men vary the distribution and content of meals they ingest during the day based on the type of work stress they experience and perceived job control. None of these models, however, has been explored in samples of patients with SCD.
Other studies have reported a relationship between increased stress and eating; some individuals increase their food intake in response to heightened stress levels. Although commonly thought to be unique to individuals who eat emotionally or with diagnosed eating disorders, this pattern of increased dietary intake in response to stress has been documented in nonclinical samples. Because the topic of changes in dietary intake has not been examined in patients with SCD, it is difficult to estimate with certainty whether they increase or decrease their dietary intake in response to pain as a stressor.
Dietary intake can significantly influence body weight. To date, few studies with patients who have SCD have examined the frequency with which they present as underweight and normal weight, and even fewer studies, overweight and obese. This may be indicative of an assumption that patients with SCD are underweight or normal weight at best as a function of their poor nutritional and disease status.
In other chronic pain populations, investigations of weight status and the impact of weight on pain have increased. For example, there is an established positive relationship between osteoarthritis and weight regardless of the location of the affected joint (i.e., knee, hip, hand, neck). This association may exist, in particular among arthritis patients, because pain contributes to inactivity and a fear of movement secondary to pain (kinesiophobia), which may result in weight gain. In addition, being overweight has been shown to be an important predictor of painful conditions, such as lower back pain. Emerging evidence suggests that the association between persistent pain and overweight status may be mediated by inflammatory and endocrine processes and not simply biomechanical factors. Given these findings and their implications regarding effective management of pain, as well as the lack of specific data about adult patients with SCD and weight, it is important to determine whether overweight status is associated with increased pain in patients with SCD. Although it is possible that SCD-related pain is similar to other types of pain in this regard, it is also possible that increased pain is associated with decreased weight in patients with SCD if caloric intake is substantially decreased during painful episodes.
In general, the dietary patterns of individuals with chronic medical illnesses, including chronic pain, have not frequently been studied. To date and to our knowledge, few studies, if any, have evaluated the effects of weight on reports of pain and the presence of pain on dietary intake in adult patients with SCD. When these relationships have been explored, dietary factors associated with SCD have only been investigated in the context of developmental delays in children and adolescents (e.g., delayed growth and sexual maturation). These studies typically yield recommendations for improvements in the nutritional status of children with SCD, but few recommendations exist for the management of adult macronutrient intake. Consequently, the sequelae of better physical functioning and increased weight on patterns of overweight and obesity (Zimulti canadian is an appetite suppressant diet pill) in SCD are not well understood. In order to develop appropriate recommendations and adequately educate patients about management of their disease, it is crucial to begin to understand the effects of chronic pain on patterns of eating and weight in adult patients with SCD.
The current exploratory study evaluated the general frequency with which patients who have SCD are underweight, normal weight, overweight or obese. To date and to our knowledge, we are the first to examine the association between patients’ weight and reported pain levels, as well as the reported interference of pain in the lives of adult patients with SCD. We retrospectively evaluated patients’ reports of their patterns of dietary intake during pain episodes and the perceived relation of their body weight to pain. We tested a hypothesis that dietary intake would be reduced and dietary content would be altered by chronic pain. We believe this study to be the first to explore dietary intake in the context of pain in patients with SCD, and one of few studies to document and consider the relation between weight and pain in SCD.
