Diet and Nutrition

Nutrition

by Catherine Smith, Registered Dietitian

Who this is for?

Good food choices are necessary to help you be and feel your best. Yet, for many reasons, all of us from time to time, don’t make the best meal and snack choices. The following tips and information are designed to help adults living with pain select smart, nutrient‐dense foods more often. There are food ideas to help you plan ahead to make the most of your time and energy when you feel well enough to prepare healthy meals and snacks as well as tips to help manage unwanted side effects of pain medication.

A few Basics on Healthy Eating: Canada’s Food Guide

Canada’s Food Guide (CFG) can help people living with pain know what amount of food they need and what type of food is part of a healthy eating pattern. Following the pattern in CFG will help you get enough vitamins and minerals and other nutrients for vitality and health.

The CFG eating pattern meets Canadian nutrient standards for vitamins and minerals called Dietary Reference Intakes (DRIs). The DRIs summarize latest research findings about the amount of each nutrient and calories that are needed for good health and the prevention of chronic disease. Following CFG will also help avoid the negative effects of consuming too much of any specific nutrient.

CFG ensures an adequate intake of carbohydrate, protein and fat in the diet for different age groups. CFG suggests for adults 19 years of age and over an eating pattern that provides about 45‐65% of total calories from carbohydrate, 10‐35% of total calories from protein and 20‐35% of calories from fat (Eating Well With Canada’s Food Guide 2007; pg. 4). This is achieved by eating from each of the four food groups plus a small amount of added oils and fats. The recommended number of servings is different for people at different stages of life and is different for males and females. Canada’s Food Guide is found at this link: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

RECOMMENDED NUMBER OF FOOD GUIDE SERVINGS PER DAY

As well as a small amount (30‐40 mL or about 2‐3 tablespoons) of unsaturated fat each day (Eating Well With Canada’s Food Guide 2007; pg. 5), when you have a moment, review CFG and take a look at the portion size descriptions of Food Guide servings. They are not very large.

What type of food should people choose?

The type of food that people eat is just as important as the amount. Try to do the following:

  • Eat at least one dark green and one orange vegetable each day.
  • Have vegetables and fruit more often than juice.
  • Make at least half of your grain products whole grain each day.
  • Consume lower fat milk products.
  • Have meat alternatives such as beans and lentils often.
  • Eat at least two Food Guide servings of fish each week.

Putting Canada’s Food Guide Into Practice

A good exercise to help you learn Canada’s Food Guide is to keep track or make a tally of the food you eat for a day or two. Compare the amount of food you eat in a normal day to the recommended number of Food Guide servings for each of the food groups. Take note of the food groups where you are meeting or exceeding the recommended number of food guide servings. Also compare the type of food recommended in Canada’s Food Guide. This exercise will help you to identify what changes you can make to follow the healthy eating pattern.

If you decide to make long‐term changes to your diet, the best place to start is to have a “SMART” goal. A SMART goal is Specific, Measurable, Attainable, Realistic, and Timely. Writing a SMART goal takes a bit of thought. For example, instead of a goal statement “to eat more fish,” a SMART goal statement would read “I will eat one more serving of fish (char, salmon or trout) each week for dinner at home for the next month.”

With your goal in mind, you can then write down small steps or strategies to help you reach your goal. These small steps could include who, where and when you will buy fish, and how you are going to prepare or season the fish, and what will accompany it. You may be more committed if you share your strategies or ideas with another. Consider involving family or your “life partner” in your goal setting so they can support your efforts. Keep track of your progress and look for the triggers that cause you to lapse.

NUTRIENTS AND ANALGESIA

Omega Three Fatty Acids

Some dietary components have been shown to relieve pain in some people. Analgesia and omega three fatty acids eicosapentanoic acid (EPA) and docosahexaenoic acid (DHA) from fatty fish, have been of research interest among adults with long standing rheumatoid arthritis. Fish oil supplementation has be shown in some studies to reduce tender joint counts and decrease the use of non‐steroidal anti‐inflammatory drugs (NSAIDs) among people with rheumatoid arthritis (Forchielli, 2011 pg. 224, 230; James, 2010; pg. 316).

Though research in this area is preliminary and limited, the argument to use fatty acid supplements along with standard therapy in the treatment of rheumatoid arthritis is strong (James, 2010; pg. 316). While the optimal dose of omega three fatty acids for pain treatment is not known, some pain specialists recommend 1 gram/day of fish oil supplement to their chronic pain patients (Pereira, Shir, 2008; pg .2). Since there are health risks from taking excess amounts, talk to your doctor about an appropriate daily dose for you (Forchielli, 2011, pg. 232).

Canada’s Food Guide recommends two servings of fish per week (Eating Well With Canada’s Food Guide, 2007; pg. 23). Char, herring, mackerel, rainbow trout, salmon and sardines have very high amounts of omega three fats EPA and DHA. Remember, EPA and DHA are just a couple of nutritional benefits associated with regularly eating fish.

Vitamin D

In 2010, a panel made up of experts from both Canada and the United States, reviewed the latest science related to vitamin D. A report was published by the Food and Nutrition Board of the Institute of Medicine, updating the daily recommended requirements for vitamin D. The revised DRIs for vitamin D were based solely on evidence supporting its role in bone health (Institute of Medicine, 2011; pg. 2). The best known function of vitamin D is the regulation of calcium and phosphorous in the blood for building bones and strong teeth.

Emerging research suggests that vitamin D may play a role in other health outcomes, including immune response (Breslin, 2011; pg. 399). Sub‐optimal levels of vitamin D and vitamin D deficiency have been associated with fatigue (Breslin, 2011; pg. 400).

Vitamin D is obtained from the diet (fatty fish, egg yolk, fortified milk, margarine and soy beverage). Milk used in the production of other dairy products such as yogurt and cheese is not required to be fortified with vitamin D. Yogurt and cheese may not be sources of vitamin D (Eating Well With Canada’s Food Guide, 2007; pg. 19).

Vitamin D can also be produced when the skin is exposed to ultraviolet B (UVB) radiation. Unfortunately, for a large part of the year in Canada (October to March), the sun is so low in the sky that its rays are not strong enough for the human body to produce the vitamin naturally (Eating Well With Canada’s Food Guide, 2007; pg. 43). Other factors such as sunscreen use and skin pigmentation can also affect the production of vitamin D through skin exposure. After the age of 50, the skin has a reduced capacity to produce vitamin D. Older adults may not obtain enough vitamin D from food even when following Canada’s Food Guide.

For 9‐70 year olds, the average amount of vitamin D a person should try to get every day is 600 IU (15 micrograms) (Health Canada; www.hs‐sc.gc.ca;). Adding a supplement containing 10 micrograms (400 IU) of vitamin D to regular food sources will ensure that individuals over 50 meet their recommended intakes (Health Canada; www.hs‐sc.gc.ca; Eating Well With Canada’s Food Guide, 2007; pg. 43).

The Tolerable Upper Intake limit is the highest average daily nutrient a person can consume that is likely to pose no risk adverse health effects. The Upper Limit for vitamin D is currently 4000 IU per day (Institute of Medicine, 2011; pg. 2).

Drugs and Nutrition

Chronic physical pain is disruptive and imposes lifestyle changes which can be very stressful. Sometimes the medication people living with pain need to take can have a significant impact on their nutritional health.

Analgesics commonly used for pain relief include acetaminophen, Non‐Steroidal Anti‐Inflammatory Drugs (NSAIDs) and opioids. Co‐analgesics are drugs that are added to or used instead of analgesics to relieve chronic pain. Examples of co‐analgesics are: antidepressants, anticonvulsants, topical agents that act as local anesthetics, muscle relaxants and antispasmodic agents. A person’s response to pain medication can vary greatly between people (Bair, 2011; pg. 146). Often people living with pain will need to try several different medications and doses to find the greatest pain relief with the least side effects.

Pain medication can have a negative impact on nutritional intake (White, 2010; pg. 558). Drug therapy can influence what kinds of food are consumed, in a good and sometimes bad way. For example, drowsiness caused by analgesics and co‐analgesics can adversely affect a person’s ability to get around and think clearly (White, 2010; pg. 558). Some medications reduce appetite while other drugs can increase appetite and cause weight gain. Drug‐ induced weight gain is a serious consideration for people living with pain and/‐or depression. People who gain an unacceptable amount of weight from their drug therapy are unlikely to stay on therapy (White, 2010; pg. 559). People living with pain should talk to their doctor about how their diet may have changed as a result of their pain medication.

Nausea

Nausea is one of the most common side effects of drug therapy in pain management that can have a profound effect on nutrient intake. Some drugs slow down the motility of the digestive system.

It is well recognized that opioids (like Tylenol 3) can cause abdominal distention, constipation, nausea and vomiting in half of those who are prescribed these drugs (White, 2010; pg. 560). Here are a few ideas that may help you manage nausea:

  • Drink clear or ice‐cold drinks between meals (instead of during meals).
  • Eat light, bland foods (such as saltine crackers or plain bread).
  • Avoid fried, greasy, or sweet foods.
  • Eat slowly and smaller, more frequent meals.
  • Avoid mixing hot and cold foods during a meal.
  • Drink beverages slowly.
  • Avoid activity after eating.

Choose foods from all of the food groups as tolerated to get adequate nutrition. If you feel nauseated when you wake up in the morning, eat some crackers before getting out of bed or eat a high protein snack (lean meat, fish or cheese) before going to bed. Adults should consult a doctor if vomiting continues for more than one day or if diarrhea and vomiting last more than 24 hours.

Managing Opioid‐induced Constipation

As a matter of general health, people need to ingest a certain amount of fiber and fluids daily and to maintain a sensible level of physical activity. About 40% of those who use opioids for pain management experience opioid‐ induced constipation (Camilleri. 2011). It is questionable whether correcting deficiencies in fiber, fluid and exercise alone can successfully treat opioid‐ induced constipation. Effective management of this type of constipation usually requires a stool softening and/or bowel‐stimulating laxative agent. Novel medications are available for opioid‐ induced constipation too. Speak to your doctor who can recommend the best agents for your condition.

Gastrointestinal Reflux

Some people living with pain take medications that cause them to experience gastroesophageal reflux. This disorder occurs when stomach acid enters the lower esophagus burning delicate tissue. The most common symptom of gastroesophageal reflux disease (GERD) is persistent heartburn, or a burning discomfort felt in the upper chest or abdomen. Make sure you tell your doctor if you have symptoms of reflux. Some of these tips may help you:

  • Avoid high fat meals and fried foods.
  • Avoid large meals.
  • Chocolate, coffee, with or without caffeine, may promote reflux in some people.
  • Other known irritants like alcohol, mint, carbonated beverages, citrus juices and tomato products may aggravate reflux.
  • Make sure you sit upright during and after eating.
  • Avoid restrictive clothing around your tummy and avoid eating three hours before going to bed.
  • Lose weight, if necessary.

Migraines

Migraine headache is a common and disabling pain disorder. Estimates from the 2009‐2010 Canadian Community Health Survey indicate that the self‐reported prevalence of migraine among the Canadian population 12 years or older is, about 10% (males 6.2% and females 14.2%) (www.statscan.gc.ca). U.S. data tells us that among girls and women, the prevalence of migraine almost triples between the age of 10 and 30 years (Sun‐Edelstein, 2009; pg. 446). Management of migraine should take into consideration environmental factors such as proper sleep hygiene, stress management, regular aerobic exercise and diet (Sun‐Edelstein, 2009; pg. 446).

Eating regular meals and snacks is important. Fasting and skipping meals can trigger migraines. Common reported food triggers for migraines include alcohol, chocolate, cheese, caffeine and monosodium glutamate (MSG) (Sun‐ Edelstein, 2009; pg. 447). Specific foods that may trigger migraines varies between people, and headaches can occur up to 24 hours after a food is ingested (Sun‐Edelstein, 2009; pg. 447). Consider keeping a detailed food and headache dairy over the course of several months to help you identify a relationship between certain foods and the migraine headaches you have.

DON’T FORGET, WHAT YOU EAT MATTERS!

Today, there are products on the market that can make it easier to eat well such as pre‐washed, ready‐to‐eat vegetables, fruit and entrées. In a pinch, these foods can make it easier for you to include foods from each of the four food groups in your diet (Eating Well With Canada’s Food Guide, 2007; pg. 1). Most prepackaged foods carry a Nutrition Facts table on the label to help you make informed choices. When you feel well and have the energy to cook or combine foods, here are a few simple ideas you can use that may enrich meals and snacks and give your diet a little lift.

At Breakfast:

  • Try a hard‐boiled egg topped with a sprinkle of cumin or perhaps another favourite spice.
  • Top hot cereal with dried fruit (cranberries/‐raisins) and sliced almonds or walnut pieces.
  • Add favorite nuts and seeds to fruit crisp (apple, peach or rhubarb); enjoy at breakfast topped with yogurt or anytime throughout the day.
  • Enjoy a glass of chocolate milk or a hot Latte made with milk.
  • A cold fruit smoothie may be refreshing (crushed ice, milk or yogurt whipped up with fruit).

At Lunch:

  • Spread your wrap with mashed avocado before filling.
  • Top a sandwich with something different. Try grated cold cooked beets, arugula or sorrel.
  • Combine sliced hard cooked egg, left‐over cold fish, cherry tomatoes and blanched green beans with watercress. Dress with a splash of olive oil, lemon juice, salt and pepper.
  • Blend smoked trout or cold cooked fish with lemon and parsley or mix with mayo and dill as a spread on whole grain breads or crackers.
  • Dip fresh fruit with lower fat vanilla yogurt.

At Dinner:

  • Instead of rice, make bulgar pilaf with chopped dried dates, dried apricots and toasted walnuts. Season with cinnamon, cumin and curry powder.
  • Add chopped spinach, arugula, or Swiss Chard to pasta sauce at the end of cooking.
  • Instead of French fries, make oven‐baked sweet potato fries. Bake sliced sweet potatoes drizzled with olive oil, rosemary and or thyme.
  • Have beans, peas or lentils on hand (cooked or canned) to toss on salads; add to soups or use as a base for tasty dips.
  • Add quinoa, brown rice or barley to soups, stews or casseroles to boost flavor and fiber.
  • Baked apples or pears using your favourite preserve and a sprinkle of cinnamon, can make a nice dessert.

Cooking With Others

Reflecting on family food traditions can be uplifting. When feeling unsettled, to gain a sense of control, some people choose to cook or share meals with others. Consider looking for windows of opportunity to plan and cook nutritious foods ahead of time for when your pain is more severe. You may find it helpful to use the pain diary provided on this website to identify times of the day, or days of the week or month, when your pain is most manageable. If you have the energy or inclination to cook, either by yourself or with a friend, here are a few quantity cooking ideas you could consider:

  • Wash and peel vegetables and/or fruit in advance to eat raw or cooked later in the week.
  • Bake whole grain muffins or biscuits with dried fruits or nuts. Freeze and re‐heat as needed.
  • Make your own granola in volume for single servings throughout the week.
  • Simmer various chopped dried fruit (prunes, apples, apricots and cranberries) slowly with a little water. Consume small portions with a meal or as a quick snack
  • Pre‐prepare soups, stews or sauces and freeze them in single serving dishes for re‐heating.
  • Make a pesto. Use it fresh as a spread to give breads and pasta dishes a bounce or freeze small quantities in an ice cube tray for later use in soups, stews or sauces.
  • Wrap, label with date, and freeze single servings of fresh meat or fish for later use.

If you are living with pain and side effects from your medications and are concerned about your nutritional health, you can request from your doctor a consult with a Registered Dietitian (RD) who can help provide personalized counseling and care to help optimize the nutritional adequacy of your diet. Find an RD in your area at www.dietitians.ca

References

Health Canada. Eating well with Canada’s Food Guide: A resource for educators and communicators, 2007.

Forchielli MA. ω‐3 Fatty Acids: Impact on cognitive development and inflammation. Nutrition Today. 2011;46:224‐234.

James M. Fish oil and rheumatoid arthritis: past, present and future. Proceedings of the Nutrition Society. 2010;69:316‐323.

Pereira JD, Shir Y. Reducing pain through dietary change. Clinical Nutrition Insight. 2008;34(2):1‐4.

Health Canada; www.hs‐sc.gc.ca

Dietary Reference Intakes for Calcium and Vitamin D, Report Brief. Institute of Medicine of the National Academies. November 2010.

Breslin LC, et al. An evaluation of vitamin D status in individuals with systemic lupus erythematosus. Proceedings of the Nutrition Society. 2011;70:399‐07.

Bair M, J et al. Coanalgesics for chronic pain therapy: A narrative review. Postgraduate Medicine. 2011;123(6):140‐ 148.

White R. Drugs and nutrition: How side effects can influence nutritional intake. Proceedings of the Nutrition Society. 2010;69:588‐564.

Camilleri M. Opioid‐induced constipation: Challenges and therapeutic opportunities. The American Journal of Gastroenterology. 2010;106:835‐842.

Sun‐Edelstein C. Foods and supplements in the management of migraine headaches. Clinical Journal of Pain. 2009;25(5):446‐452.

Lyon P, et al. Continuity in the kitchen. International Journal of Consumer Studies. 2011;35:529‐537.