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Turmeric, a super spice for pain

If you do a quick search about Turmeric on the Internet you may begin to wonder what it can’t do. The list of benefits reported is extensive and the diseases it is purported to treat are numerous. This super-spice is popping up in all sorts of interesting ways from Turmeric lattes to fermented drinks. It also has a growing body of research to back up some of the widely quoted benefits. However, it is important to note that there is a difference between food ingestion and a standardised supplement and in this article, I specifically look at standardised curcumin, one of the key active components of turmeric, and the role it has to play in pain management.

Chronic pain is defined as pain that extends beyond normal healing time or 3 months, whichever comes first. It is characterised by spontaneous pain, increased responsiveness to noxious (painful) input and painful responses to innocuous stimulus e.g. light touch or normal movement. There is both peripheral and central nervous system involvement in all types of chronic pain including neuropathic, inflammatory and nociceptive, however, changes within the central nervous system and brain are commonplace and can predominate.

turmeric_latte — Turmeric is an anti-inflammatory spice.

Curcumin has a wide range of therapeutic benefits that have potential in the management of pain including antioxidant, immune modulating, anti-spasmodic, anti-inflammatory and antidepressant. These effects, however, have to be translated into clinical benefit and accordingly, I have looked at the research in different types of pain below.

Neuropathic Pain Treatment
Neuropathic pain arises from injury or trauma to the nerves, which can result from factors such as exposure to drugs (e.g. chemotherapy agents), metabolic disease (e.g. diabetes type 1 and 2), or lesions (e.g. multiple sclerosis). Preliminary research suggests that curcumin may help prevent pain associated with diabetic neuropathy when taken in combination with some blood sugar lowering medication.

Post-Surgical Pain
Persistent pain occurs in 50% of individuals post surgery, with opioids being the most common strategy for pain management. In a previous article I have discussed how extended use of opioids post-surgery can actually contribute to further pain development and so short-term use only is recommended. Fortunately, curcumin has a dose-dependent effect on post-surgical pain and can improve pain threshold and recovery rates. The other key factor is that curcumin can potentially reduce the risk of opioid tolerance and dependence – a definite bonus in my opinion!

Inflammatory pain
Curcumin is well known for its inflammation dampening effects and I have previously written about effective use in highly inflammatory conditions such as psoriasis and rheumatoid arthritis. Osteoarthritis is another area where use of curcumin may benefit pain levels, and also reduce the use of analgesic pain medications such as paracetamol and non-steroidal anti-inflammatories (NSAIDs), which with ongoing use are associated with significant side effects.

Several high-level reviews of the clinical evidence indicate that osteoarthritic pain can be reduced in 8-12 weeks of treatment using standardized turmeric extracts. The doses of curcumin involved were higher than most over the counter supplements currently available however the range was quite wide (400-1000mg curcumin), which means it is possible to achieve these results with lower end therapeutic doses.

Pain and mood
Depression commonly occurs with chronic pain, some studies saying it is evident in up to 70% of people with chronic pain. The association is bi-directional; those with depression may be more prone to increased pain perception and conversely, those with chronic pain are more likely to develop depression. Here curcumin may play dual roles, helping to relieve both chronic pain and depression through independent effects. While studies haven’t been specifically run in a patient population with both chronic pain and depression, independent studies in pain and also depression show positive benefit.

Safety
With all the indications for curcumin outlined above, it is important to note that individual prescribing is important both for efficacy but also for safety. Fortunately, it is generally regarded as safe, even higher dose ranges however it is important to check in with either a naturopath, holistic nutritionist (with training in supplement prescribing) or pharmacist about any potential risks associated with medication co-prescribing. I have been specific in my recommendation about healthcare providers as it is important to ask a professional who knows about curcumin and any associated risks. Your GP or specialist may simply not know, as this is not their area of expertise.

While I have only included research specific to curcumin, one of the active components of turmeric, daily inclusion of fresh or powdered turmeric is great for general health and wellbeing. For inspiration, I have included a couple of recipes below. If you are looking for a therapeutic effect from turmeric, via curcumin supplementation I recommend you a. source a quality product and b. run it past your naturopath because while it is a super-spice, there may be something more specific or appropriate to your health or pain issue.
Recipes

Turmeric Dressing
This dressing is a great addition to salads for anyone with inflammatory conditions or just to maintain good health. The recipe is as follows:

Ingredients
4 cloves garlic (optional)
¼ cup + 2 tablespoons extra virgin olive oil OR cold pressed, unrefined avocado oil
3 tablespoons lemon juice
2 teaspoons raw honey (optional)
2 teaspoons powdered turmeric
½ teaspoon Dijon mustard
⅛ teaspoon black pepper
¼ unrefined salt

Method
Place all ingredients in a mini processor and process until smooth and creamy. Alternatively, crush the garlic into a jar and add all the other ingredients. Shake well. Double or triple quantities can be made and kept in the fridge.

Cauliflower Florets with Ginger, Turmeric, and Cumin

Ingredients
1 large head cauliflower
Salt and pepper to taste
2 tablespoons olive oil, divided
1 teaspoon freshly grated ginger
1 teaspoon ground cumin
1/2 teaspoon ground turmeric
Small handful of parsley, chopped
Preheat the oven to 180°C.

Method
Rinse the cauliflower and break it up into larger florets. Use the stalk as well, just cutting it up into large chunks. Season each steak with salt and pepper on both sides. Cover an oven tray in a coating of olive oil, about 1 tablespoon. Spread the florets over the tray. Whisk together the remaining 1 tablespoon of olive oil, ginger, cumin, and turmeric. Brush or spoon the mixture on the cauliflower florets.
Roast in the oven until tender, about 15-20 minutes. Garnish with parsley and serve.

References
Daily, J. W., Yang, M., & Park, S. (2016). Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. Journal of medicinal food, 19(8), 717-729.

Sun, J., Chen, F., Braun, C., Zhou, Y. Q., Rittner, H., Tian, Y. K., … & Ye, D. W. (2018). Role of curcumin in the management of pathological pain. Phytomedicine.

Acne low-down on FB Live

In my first FB Live with Elysia Humphries from Vibe Natural Health we discuss why acne is so impactful on self worth, why so many people with acne feel like they have tried everything but still aren’t getting results, and look a some of the key factors that contribute to acne from a holistic perspective. I also do a lot of hand talking!

The vitamin D and acne connection

Vitamin D deficiency is known to play a role in many inflammatory skin conditions, and certainly is seen to be a contributing factor in acne. Acne is an inflammatory skin condition with both systemic inflammation and local inflammation within the skin, even at the very early micro-comedone stage of development. The causes of local inflammation can be directly linked to the influence of systemic drivers however; local factors play a significant role as well. This article looks at the role of vitamin D as a potential regulator of local immune and inflammation processes that drive acne.

aid baby cure drug — Photo by Pietro Jeng on Pexels.com

Propionibacterium acnes (P acnes) are bacterium which resides naturally on this skin as part of the wider skin microbiome. It is also the bacterium associated with the development of open comedones and pustules. Generally over-growth of P acnes is kept in check by other bacteria on the skin, however given the right conditions it becomes a potent inducer of local skin immunity, which results in significant inflammation. This pathway is driven by part of the peripheral immune system, and it is here where vitamin D, and in fact vitamin A (which I will write more about soon) can play a role in dampening down acne severity (Agak et al., 2014). Specifically vitamin D regulates the growth and development of both skin and sebum producing cells, effectively achieving an anti-comedogenic effect. It is also associated an increase in antimicrobial peptide production within the skin, reducing the potential for P acnes to induce immune processes and as such a reduction in inflammation.

So, how strong is the association between vitamin D levels and acne?

One recent study (El-Hamd et al., 2018) looked at vitamin D levels in patients with acne before and after treatment for isotrentinoin (Oratane, Roaccutane; generally used for cystic acne). The study aim was to assess if there was a correlation between vitamin D levels and acne severity. Ninety patients with acne were age and sex matched with 60 control subjects. Serum vitamin D levels were measured at baseline and then after 3 months treatment with isotretinoin. A significant inverse relation between vitamin D levels and acne severity was seen i.e. the lower the baseline vitamin D, the worse the severity of acne. Treatment with isotrentinoin, brought about resolution of acne in some participants, which resulted in increased levels of vitamin D. The increase levels of vitamin D were unlikely to be brought about by isotrentinoin, instead either low vitamin D levels play a role in the development of acne or that acne has a negative effect on vitamin D synthesis.

At this point I would like to note, that despite the positive effect associated with isotrentinoin use, it is a drug with a significant side effect profile and doesn’t necessarily resolve the underlying drivers of acne i.e. it is effectively a bandaid. I will write more about this topic soon.

In another study looking at the role of vitamin D in acne, vitamin D deficiency was found in 49% of patients with acne and only 22.5% for those without. The study included 80 patients with acne and 80 healthy controls. Again the severity of acne and inflammatory lesions was associated with the degree of vitamin D deficiency. In a follow up trial within the same cohort of patients, 39 out of 80 patients showed improvement in the number of inflammatory lesions post supplementation with vitamin D. The authors noted that vitamin D assessment is of particular note for patients with inflammatory lesions (Lim et al., 2016).

Relating this back to an individual level, how do you know if supplementation with vitamin D will help? The first step is to get vitamin D levels assessed as part of a holistic work up. Vitamin D alone is unlikely to be a miracle cure, however it may be part of an effective overall treatment plan. I will add my usual caveat with regard to vitamin D supplementation, which is to establish baseline serum levels before taking supplemental vitamin D and it is worthwhile seeing a health care professional such as your naturopath or nutritionist to do so. Sunshine and vitamin D rich foods are also important for maintaining healthy levels. If acne impacts you personally and you want a holistic assessment and individualised treatment plan developed to help treat your acne, please book into make an appointment to see me, contact me here, or read more about my Skin Healing Program here.

References:

Agak, G. W., Qin, M., Nobe, J., Kim, M. H., Krutzik, S. R., Tristan, G. R., … & Kim, J. (2014). Propionibacterium acnes induces an IL-17 response in acne vulgaris that is regulated by vitamin A and vitamin D. Journal of Investigative Dermatology, 134(2), 366-373.

El‐Hamd, M. A., El Taieb, M. A., Ibrahim, H. M., & Aly, S. S. (2018). Vitamin D levels in acne vulgaris patients treated with oral isotretinoin. Journal of cosmetic dermatology.

Lim, S. K., Ha, J. M., Lee, Y. H., Lee, Y., Seo, Y. J., Kim, C. D., … & Im, M. (2016). Comparison of vitamin D levels in patients with and without acne: a case-control study combined with a randomized controlled trial. PloS one, 11(8), e0161162.

Mind Over Matter

This month I have been delving into New Scientist again and one article in particular really sparked my interest. Called “Mind Over Matter”, the author David Robson outlines and supports the assertion that changing your attitude can have profound benefits on your health (Robson, 2018). In this day and age of metaphysical thinking this may not seem like a mind-blowing-ly new concept, however I often find the mind over matter approach being thrown about without a lot of research to back it up. So when the article outlined studies to support this concept I suddenly got a bit more interested.

One researcher in this area, AliaCrum had a key insight to mind over matter when she was studying the placebo effect. She realised that if the effectiveness of a drug can be influenced by expectations, then perhaps expectation could influence other situations as well. Yes, it seems so, and in particular our physiology. The article goes on to cite a number of examples of mindset and expectation influencing physiology including:

Explaining to half of a group of cleaners that their work burnt 200 calories every hour, meeting the daily requirements for exercise. Over the next month thecleaners lost about 1kg and their blood pressure had dropped from elevated to normal. The control group showed no change.
Feeling fit or perceiving fitness can influence physical fitness. People who were more pessimistic about their level of fitness were more likely to die during the survey period than those who were more optimistic.
How you think about food impacts the way our bodies respond to it. Feeling deprived or thinking food is overly healthy (i.e. most diets) can lead to an increase in hunger hormones resulting in less satiety and more fat storage. The key is to mindfully eat, savouring and enjoying each mouthful so it becomes more like an indulgent treat, which can lead to lower hunger hormones and a greater sense of satisfaction.
Focusing on stress as having negative effects is actually more debilitating and leads to greater fluctuations in the stress hormone cortisol, than seeing stress as a positive, motivating factor.
Even ageing can be a healthier process if you have a positive outlook about it. Those who report feeling positive about getting older live on average 7.5 year longer and are less likely to respond to stress or develop inflammation than those who have negative associations.

The research that really impacted me was about sleep and insomnia. Those that fit into the category of ‘complaining good sleepers’, that is, those who think they are insomniacs or believe they have poor sleep even though monitoring suggests otherwise are more likely to experience increased daytime sleepiness, higher blood pressure, depression and anxiety. By contrast ‘non-complaining bad sleepers’ have less of these effects, so to confirm, less sleep but less side effects. By contrast, I consider myself a ‘complaining bad sleeper’ based on absolutely no monitoring (!) and so as an experiment I decided that for 1 week I would have a positive mindset no matter how much sleep I had had the previous night. Specifically, for me the issue is daytime fatigue, specifically mental fatigue. During the week I found that choosing to over-ride my concern about lack of sleep allowed me to get on and perform tasks I usually keep back until I have slept well (or at least, think I have slept well). I felt quite liberated from my own worry, and the researcher who showed the above effects indicated that worry about sleep has more negative effects on our health than poor sleep alone. Positively alarming!

So how can we use mindset to improve our health? I have jotted down a few ideas but I think there are many other empowering ideas in this field.

Savour your food
Start embracing the concept of growing older, in whatever way you can. I have a great role model in my mother, who at 70+ is going on 45.
Think about and if possible set a positive expectation prior to exercising or eating
Let go of sleep worry! Note to self! I did this by setting a positive intention for mental clarity and energy for the day

If you have any empowering ideas to contribute please comment below.

Reference:

Robson, D. (2018, August). Mind Over Matter. New Scientist, issue 3192, pp. 29-32.

The connection between our gut health and skin

The Gut-Skin Axis

The health of the gut microbiome and its impact on wider health has seen an explosion of research, and with the advent of DNA sequencing our understanding of the microbiome and its effects on health is growing. We now understand that the influence of the gut microbiome extends beyond the gut, impacting on distant organs and systems either positively or negatively depending on the composition of microbiota. These wider effects are known to influence skin health, and this article will review the specific influence on acne.

A cardinal function of the microbiota is to maintain intestinal barrier function as well as being important regulators of immune function and inflammatory responses. Changes in composition of the microbiota, leading to a state of microbial imbalance (dysbiosis) are associated with gut barrier dysfunction and permeability, or leaky gut. Dysbiosis can also activate the immune system and lead to inflammation, both at a local gut level and systemically, and this is effect is thought to be modulated by the degree of gut ‘leakiness’.

So how does this influence the skin? Dysbiosis has the potential to negatively impact skin health in numerous ways. The presence of pathogenic bacteria in the gut leads to an accumulation of toxic metabolites, which can access systemic circulation. These metabolites can accumulate in the skin and disrupt skin barrier integrity, reduce skin moisture content and disrupt the production of healthy skin cells (Salem, et al. 2018).

Image: Kelly, et al. 2015

Acne is an inflammatory skin condition and it is now known that inflammation precedes pustule development, even in preclinical micro-comedones (Mochtar, et al. 2018). The concentration of certain inflammatory molecules is also linked to the severity of acne. Both the overgrowth of commensal (normal) bacteria and/or the presence of pathogens can drive inflammation systemically, which leads to increased inflammatory chemicals in the skin and thus driving acne progression (Salem, et al. 2018). This implies that they degree of dysbiosis may also influence the severity of acne in susceptible, however this has not been firmly established as yet.

There is a brain connection involved in acne pathogenesis also, and so rather than just the gut-skin axis, it can be extended to the brain-gut-skin axis. This concept is supported by the frequent association of mood disorders such as anxiety and depression, coupled with gastrointestinal complaints and acne (Kelly, et al. 2015). Psychological stress is thought to drive the gut microbiota to produce different neurotransmitters, or trigger the release of neuro-chemicals such as substance P from the specific intestinal cells. Substance P can trigger inflammatory mediators both locally and within the skin. The net effect is increased leaky gut, leading to inflammation systemically and within the skin.

So what influences negative changes in the gut microbiota? Well as mentioned above stress plays a role. Also well known is that acne is particularly influenced by both high fat and high glycemic carbohydrate diets. This pattern of eating has a strong negative influence on the gut microbiota, which thrives on high fibre, complex carbohydrates and polyphenol rich foods. Other negative influencers include alcohol, food additives, certain medications such as non-steroidal anti-inflammatory drugs and too much or too little exercise.

The dietary pattern that supports a healthy skin has been well established and correlates well to the foods that support a healthy microbiome. For more on the specifics of what to consume to help prevent or manage acne click here: Dietary Influences on Acne. However, if eating all the ‘right’ foods and avoiding those that drive acne and a dysbiotic microbiome still aren’t reducing acne severity, then the factors influencing acne development and severity may be broader. If you you need more support to heal your acne I can support you to make the changes you need to feel better in a way that is manageable and works in your life. To read more about my Skin Healing Program click here.

References:

Kelly, J. R., Kennedy, P. J., Cryan, J. F., Dinan, T. G., Clarke, G., & Hyland, N. P. (2015). Breaking down the barriers: the gut microbiome, intestinal permeability and stress-related psychiatric disorders. Frontiers in cellular neuroscience, 9, 392.

Mochtar, M., Murasmita, A., Irawanto, M. E., Julianto, I., Kariosentono, H., & Waskito, F. (2018). The Difference in Interleukin-19 Serum on Degrees of Acne Vulgaris Severity. International journal of inflammation, 2018.

Salem, I., Ramser, A., Isham, N., & Ghannoum, M. A. (2018). The Gut Microbiome as a Major Regulator of the Gut-Skin Axis. Frontiers in microbiology, 9.

Acne is more than skin deep

The burden of acne is more than skin deep. Strongly impacting on negative self-image and perceived stress, acne not only causes stress but is also made worse by stress. It is now well established that stress contributes to the development of acne but until this year there have been no studies looking at stress management as a direct treatment intervention. A report published this year in the International Journal of Dermatology details the methods and results of an 8-week experimental study in 30 women with acne undergoing a specific stress reduction process called the Pythagorean Self-Awareness Intervention (Chatzikonstantinou, et al. 2018)

While there was a treatment group and a control group in the study, the study was non-blinded meaning that those who didn’t partake in the self-awareness program knew they weren’t receiving treatment. In both groups each woman’s clinical acne stage was measured, as well as acne-related quality of life (i.e how the acne impacted them), their perceived stress, and positive and negative affect i.e their mood and emotions.

After 8 weeks 14 out of 15 women in the treatment group showed improvement in their acne stage, and this improvement was regardless of baseline acne stage and age. There were also significant improvements in perceived stress as well as negative thoughts and emotions. There were no reported side effects. In the control group only 4 women showed improvement in their acne stage, which reinforces that the improvement in the treatment group is not just related to the natural course of the condition, rather the results of the active self-awareness intervention.

Given the results it is astounding that there has been no previous research in this area. While this is a small pilot study, the outcomes are significant and strongly reinforce that stress and its impacts on our bodies and overall health is not to be ignored, and further that working to reduce stress can have profound healing effects on our mental physical wellbeing.

The study did not discuss the specific physiological mechanisms of the self-awareness intervention however two possibilities come to mind. Firstly this could be a top down effect on the gut-brain axis. Stress negatively impacts the gut microbiota, and a dsybiotic microbiota has the potential to drive the skin inflammatory processes, which in turn drive acne (Salem, et al. 2018). Secondly, stress impacts the skin-brain-immune axis locally within the skin, influencing the expression of sebum receptors and effectively supporting an environment that favours the growth of P.acnes, the bacteria that contributes to acne formation (Dreno, 2017).

To the specific intervention, the Phythagorean method has previously been used to effectively reduce stress in Multiple Sclerosis and insomnia. Once the process has been taught it can be used on an ongoing basis and incorporated as a health management strategy at any time in the future. The basis of the technique is daily cognitive processes that support self-awareness and self-control including techniques such as self-reflection and introspection, reviewing the day’s events and importantly the thoughts and emotions that accompanied those events, and then developing strategies for changing responses that weren’t productive. Questions that could be asked include; ‘What did I do well’, ‘What could I improve’, ‘Is there something I should have done but didn’t do’?

When studied in other conditions such as multiple sclerosis many benefits have been shown including improvements in memory and cognition, reduced stress and anxiety, improved sleep and the adoption of healthy habits including better eating habits and more exercise.

While the Phythagorean method was used in this study, what the study shows overall is that stress reduction helps to improve acne, which leads to the tantalising thought that perhaps other stress reduction techniques, when applied daily and consistently will also help. Mental food for thought!

References:

Chatzikonstantinou, F., Miskedaki, A., Antoniou, C., Chatzikonstantinou, M., Chrousos, G., & Darviri, C. (2018). A novel cognitive stress management technique for acne vulgaris: a short report of a pilot experimental study. International journal of dermatology.

Dréno, B. (2017). What is new in the pathophysiology of acne, an overview. Journal of the European Academy of Dermatology and Venereology, 31, 8-12.

Salem, I., Ramser, A., Isham, N., & Ghannoum, M. A. (2018). The Gut Microbiome as a Major Regulator of the Gut-Skin Axis. Frontiers in microbiology, 9.

A high fat diet worsens post-operative pain and inflammation

Obesity commonly correlates with increased pain. One of the mechanisms for this is relatively straightforward; having central adiposity (fat around the stomach region) or being obese is associated with low-grade chronic inflammation, and this, in turn, is associated with a greater incidence and severity of chronic pain conditions. In the recent study authors (Song. et al, 2018) wanted to study the effects of diet and obesity on postoperative pain. There were 2.7 million surgeries performed in 2016 according to the Australian Institute of Health and Welfare. Each surgery is associated with some degree of acute pain, and the severity and duration of acute pain experienced is a risk factor for the development of chronic pain. So any modifiable factor that increases pain intensity or duration post surgery is worthy of note, as it may help to reduce progression to chronic pain.

surgery

The study had some interesting findings, one of which was that negative outcomes occurred with greater frequency in males than females. To summarise the findings, a high-fat diet:

Resulted in prolonged pain particularly in males.
Delayed skin wound healing and rates of nerve regeneration.
Caused increased macrophage (immune) activity and sensitivity, leading to increased inflammation.

Alarmingly the study implied that even 1 week of high-fat eating in the lead up to surgery can contribute to the above effects. However, on the flip side, a moderate fat diet in the two weeks leading up to surgery can help mitigate the effects even if no weight loss is achieved.

The authors noted that changes to the composition of the gut microbiome are proposed to play a role in the low-grade inflammation in obesity or during high-fat diets. The changes in composition lead to increased endotoxin production, which is seen as a danger by the immune system leads to increased immune activation and as such inflammation in both the peripheral and central nervous systems. The authors also note there are likely other factors that account for the effects of dietary fat on post-operative pain but the above mechanism has a potentially significant role.

So what are the potential take-home points from this study?

For both men and women, but men, in particular, prepare for surgery by consuming a lower fat diet (30% of total kilojoule intake or less).
Of the 30% or less fat intake, choose a predominance of healthy fats including monounsaturates (olive oil, avocado, nuts & seeds) and polyunsaturates (SMASH fish – salmon, mackerel, anchovies, sardines and herrings, chia seeds, flax seeds).
Increase vegetable intake to at least 5 serves (cups) per day, legumes and whole grain intake, which will provide fibre to bind fats and help eliminate before they are absorbed. These foods will also support a healthy microbiome, with less endotoxin production e.g all vegetables, rolled oats, brown bread, wholemeal pasta, quinoa, lentils, and beans.

Reference: Song, Z., Xie, W., Strong, J. A., Berta, T., Ulrich-Lai, Y. M., Guo, Q., & Zhang, J. M. (2018). High-fat diet exacerbates postoperative pain and inflammation in a sex-dependent manner. Pain, 159(9), 1731-1741.

Relief with opioid discontinuation

Managing persistent or chronic pain is complex. Frequently there is a lack of objective reason for persistent pain yet it is real, personal and subjective and people with persistent pain are of then desperately seeking effective pain relief. I recently attended an “Explain Pain” course in Cairns (which was lovely and warm), which looks at ways to reconceptualise pain from a modern neuroscience perspective. How does this help? Well knowledge is power. There is a growing body of research showing that we can target our natural analgesic systems with simple but effective education about pain. This is particularly pertinent given the numbers of people suffering with persistent pain and the failure of common pain medications to effectively manage pain.

In Australia opioid prescribing is frequent, with up to 72% off people with both cancer and persistent non-cancer pain taking prescription opioids. However, unlike those in acute pain, in those with persistent pain the prescription and ongoing use of opioids may not be wise. There is significant evidence of ineffectiveness in persistent pain along with risk of dependence. The mechanisms behind the loss of effectiveness with long term use of opioids are gradually coming to light and include factors such as the metabolites of opioids being perceived as a threat to the body resulting in ‘alarm’ signals and loss of opioid receptors over time, leading to less effective pain relief.

Discontinuation of opioids for those who have been on long-term therapy may be seen as a risk due potential changes in pain intensity. Little was known about the potential changes until a recent study looked at this very issue. Following opioid discontinuation in 551 patients, which chronic pain researchers sought to characterise pain intensity over a 12-month period. To make effective comparisons researchers also compared pain intensity data from the participants 12 months prior to discontinuation. A 0-10 pain numeric rating scale was used to compare pain scores over time.

Researchers identified for pain classes, which were characterised by their post discontinuation pain levels:

no pain
mild clinically significant pain
moderate clinically significant pain
severe clinically significant pain.

The changes in pain intensity over time showed a small but statistically non-specific reduction over 12 months in all characterised pain trajectory classes, with those with mild and moderate pain experiencing the most significant pain reductions post-discontinuation. Importantly pain did not increase in any of the groups, and may slightly improve in those with mild to moderate pain at the time of discontinuation. This research is significant as it indicates that those in persistent pain may actually be better off without opioid medications.

Over the next few months I will write more about persistent pain and how it can be more than just managed but also effectively treated.

Reference:

McPherson, S., Smith, C. L., Dobscha, S. K., Morasco, B. J., Demidenko, M. I., Meath, T. H., & Lovejoy, T. I. (2018). Changes Ii Pain Intensity Following Discontinuation of Long-Term Opioid Therapy for Chronic Non-Cancer Pain. Pain.

Food marketing to kids?!?

UPF Have you ever perused the food options on the shelves of the supermarket looking for the healthiest option, and then read the ingredients only to find it was loaded with sugar…or something that sounds like sugar but you just can’t be sure? A recent Australian study (Pulker et al., 2018) sought to understand the impact of nutrition marketing and health claims found on the packaging of ultra-processed foods (UPF). An UPF is an industrially processed food, which may include colours, flavours, sweeteners and processing aids, or undergoes processing for which there is no domestic equivalent i.e. we can’t recreate these foods in our own kitchen. They are also described as hyper-palatable and are commonly marketed at children. Examples include breakfast cereals, snacks, confectionary items and breakfast meal replacements.

To carry out the assessment the researchers looked at the packaging information of UPF from 5 different manufacturers. The ingredient lists were examined for the addition of sugar as well as nutrition and health related claims, and food marketing.

The results were alarming. Ninety-five percent (95%) of UPF contained added sugar. There were 34 different terms used to describe sugar (I can’t even come up with half that amount). Just over half of UPF were moderate health star rated or had nutrition claims…yes these were the same foods that had added sugar. Almost all used food marketing, with half of those reviewed using marketing techniques aimed at children. So despite many foods containing sugar and being less than health options they are being marketed as nutritional.

The researchers were concerned about the inappropriate or inaccurate statements (in some cases) particularly those aimed at children. They recommended that surveillance of UPF be increased with the aim of reducing deceptive marketing practices. Additional recommendations include clear identification of sugar, correct identification of nutritional quality (or lack of quality), and a raft of other suggestions to increase clarity around food choices with relation to UPF.

From my perspective I hope these changes come about. In the meantime when shopping in the middle aisles (instead of around the edges of the supermarkets where the fresh food is located), aim to choose minimally processed foods or those with less ingredients e.g. muesli or rolled oats instead of cereals that contain added sugar. Another approach I take is to choose healthy daily basics such as rolled oats for breakfast and then when I want to indulge in a sweet treat (chocolate peanut butter icecream anyone?), I really go for it but the choice is mine rather than being hidden under layers of marketing guff.

Reference: Pulker, C. E., Scott, J. A., & Pollard, C. M. (2018). Ultra-processed family foods in Australia: nutrition claims, health claims and marketing techniques. Public health nutrition, 21(1), 38-48.

Throwing the baby spinach out with the bath water

Recently I went into a well known supermarket looking for some leafy greens to go with the dinner I was cooking. I scanned the shelves and all I could see was packets of baby spinach, rocket or mixed greens, neither on their own, both mixed with baby spinach. I felt like I was in a monoculture world of greens and wanted to run screaming from the veggie aisle (not really, it was more of a sigh and start to think of alternative dinner plans). Dramatics aside, I did on the spot decide to boycott baby spinach for life…well for a little while anyway. I probably need to admit at this point that I am not a fan of baby spinach, I think it is overrated, over consumed and I would love to see more alternatives. While this opinion goes against the advice found in the popular media, which is ‘eat spinach, its a super green’, it isn’t isn’t an uninformed opinion so I have outlined my reasons for boycotting baby spinach below:

1. We are missing out on variety, which has an impact on the health of our microbiome. Not just through the over consumption of baby spinach, but generally reducing our food choices down to a few varieties that are available in the supermarket. I do think greens are an important part of our nutritional intake so consuming them regularly is ideal but mixing it up is key. Add some good old iceberg to your smoothie, celery, zucchini, rocket or even mixed leaves with baby spinach (see a more extensive list of alternatives at the end of the article). This will give you a wider intake of plant nutrients and an interesting start to the day!

2. It is high in oxalates or oxalic acid. Oxalic acid is a naturally occuring molecule which if eating in too large quantities can bind up minerals such as calcium and magnesium from other foods eaten forming oxalates and render the minerals inabsorpbable. In excess oxalates are also linked to kidney stones and inflammation in various body systems. This isn’t necessarily an issue if you have a healthy microbiome but a quick look at the avalanche of research about the health of our microbiome as a population and I think this is an issue we all have to consider. So how do we feed the health of our gut bugs? The key is, yes you guessed it, variety. Of course oxalates aren’t a big issue for most of us if we only consume them occasionally or as part of a varied diet but if your work lunch routinely consists of baby spinach, then it may become an issue, particularly if coupled with digestive health issues.

3. Baby spinach can cause the body to release histamines, a chemical produced by the body that in excess or those sensitive to histamine is linked to headaches, allergic responses, itchiness and rashes. I had one client who was a FIFO worker in a remote mine. This client made every attempt to be healthy in a location with limited supply of fresh fruit and vegetables and so avoided the canteen and instead made his own lunches. Every day for lunch at the mine he ate a spinach and tuna salad. Over a couple of months he started to develop a hive like rash all over his body, which cleared up when he came home and ate a varied, but in his words ‘less healthy diet’. We worked out quickly that the spinach and canned tuna were the culprits, encouraging the release of histamine and leading to the full body rash. A few simple changes in diet including cutting out the spinach and canned tuna and increasing variety saw his rash clear up.

4. Finally and I have to admit it I don’t like the flavour! I know I am already biased however I would love to see more variety next time I go to the supermarket and in the meantime I am fighting the chooks for my garden greens, bug free and delicious but slightly pecked!

So the key take home I would love you to take from this diatribe against spinach is to please consider vegetable and greens variety. Apart from the nutritional value, it will make for some interesting smoothies and salads and hopefully your palate will agree.

P.S. some alternative greens – all lettuce varieties – cos, iceberg, Romaine, butterhead, oakleaf, loose leaf lettuce, field lettuce, Asian greens, rocket, kale, chard, beet green, broccoli microgreens, mustard greens, endive, curley endive, chicory, radiccio (yes it’s red/purple but still), Japanese greens (found in lettuce mixes), escarole, cress, rosette bok choy, broccoli rabe, watercress, dandelion.