Exploring The Relationship Between Chronic Pain and
Obesity: A Growing Public Health Concern
Table of Contents
Abstract...4
Introduction...5
Definitions...6
The Definitions of Overweight and Obesity...6
The Definition of Chronic Pain...7
Methods...8
Results...9
Prevalences of Overweight and Obesity in Common Chronic Pain
Conditions...9
Overweight in Arthritis...9
Overweight in Chronic Headache...10
Overweight in Low Back Pain...10
Overweight in Fibromyalgia...10
Acute Pain Vs. Chronic Pain...11
The Differences Between Acute Pain and Chronic Pain...11
Background of the Problem: Overweight and Obesity...13
The Prevalence of Overweight and Obesity...13
The Public Health Significance of Overweight and Obesity...13
The Impact on Overall Health and Comorbidities of Overweight and
Obesity...13
Under-Diagnosis and Under-Treatment of Overweight and Obesity...14
The Causes and Risk Factors of Overweight and Obesity...14
Preventing Overweight and Obesity...15
The Treatment of Overweight and Obesity...15
Background of the Problem: Chronic Pain...16
The Prevalence of Chronic Pain...16
The Public Health Significance of Chronic Pain...16
The Impact on Overall Health and Comorbidities of Chronic Pain...16
The Under-Diagnosis and Under-Treatment of Chronic Pain...17
Common Chronic Pain Conditions...17
The Causes and Risk Factors of Chronic Pain...18
Preventing Chronic Pain...18
Treating Chronic Pain...19
Over-the-Counter Medications for Chronic Pain Treatment...20
Opioids for Chronic Pain treatment...20
Prevalence...21
The Relationship Between Chronic Pain and Weight...22
How Chronic Pain Contributes to Overweight and Obesity...22
How Overweight and Obesity Contribute to Chronic Pain...23
Chronic Pain as the Result of Weight Gain...25
Current Recommendations in Primary Care...25
The Role of the Environment...26
The Barriers to Treatment...26
Patient-Level Barriers...26
Physician-level Barriers...27
System-Level Barriers...27
Discussion...27
Conclusions...28
Other Considerations...29
Depression...29
Age...30
Smoking...30
Areas for Further Research...31
Differences in Prevalence among Men and Women...31
Causes of Pain Beyond Excess Weight on the Skeletal System...31
Addiction...32
Abstract
Overweight and obesity and chronic pain are major health issues in the U.S.; the majority of adults in the U.S. are overweight or obese, and as many as 100 million people in the U.S. live with chronic pain. Both conditions are associated with many comorbidities which reinforce one another and complicate treatment.
The burden of pain is most felt in primary care; it is one of the most common complaints reported by patients in primary care, and the majority of patients seen in primary care are overweight or obese. Although the majority of overweight and obesity and the majority of chronic pain conditions are first presented in this setting, both are under-treated by primary care clinicians. Furthermore, chronic pain and overweight are often comorbid; many overweight patients have a pain syndrome, and vice versa. Pain has been described as a barrier to weight loss, and overweight and obesity are thought to contribute to some forms of chronic pain.
The purpose of this paper was to evaluate the existing research literature to determine the relationship between weight and common chronic non-cancer pain
conditions including how each condition influences the other. A comprehensive literature review was conducted to determine the relationship between overweight and four of the most common chronic pain conditions. Research was conducted to explore the
relationship further, including causes, comorbidities, contributing factors, barriers to treatment, and effective treatment strategies.
treatment of chronic pain are impacted by weight. Chronic pain also contributes to overweight and obesity, and might be both a hindrance to weight loss efforts and a contributing factor to weight gain.
Introduction
Overweight and obesity and chronic pain are major health problems in the U.S.; over 69% of adults in the U.S. are overweight or obese (National Center for Health Statistics [NCHS], 2012), and some estimates of the number of U.S. adults experiencing chronic non-cancer pain are as high as 100 million (Gaskin & Richard, 2012).
Furthermore, pain is the most common reason patients see primary care physicians (Turk & Melzack, 2001; Resnick, Rehm, & Minard 2001; Cherry, Hing, Woodwell & Rechtsteiner, 2006; McCarberg, Nicholson, Todd, Palmer, Penles, 2008; Upshur, Bacigalupe & Luckmann, 2010), and is responsible for more than 70 million visits to physicians per year (Turk & Melzack, 2001).
Commonly reported pain conditions include back pain, headache and migraine pain, neck pain, and joint pain (NCHS, 2012), and common conditions associated with chronic pain include chronic fatigue syndrome, endometriosis, fibromyalgia,
inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia (National Institute of Neurological Disorders and Stroke, 2013). The most common types of chronic non-cancer pain are back pain, neck pain, headache, and facial pain (NCHS, 2006).
Control [CDC], 2012), and chronic pain conditions such as lower back pain are also on the rise (Freburger et al., 2009).
Although the majority of overweight and obesity and the majority of chronic pain conditions are first presented in the primary care setting (Smith & Torrance, 2011; Logue, Sutton, Jarjoura & Smucker, 2000), both are under-treated by primary care clinicians (Institute of Medicine [IOM], 2011; Resnick, Rehm & Minard, 2001; Bowerman et al., 2001; Ferrante, Piasecki, Ohman-Strickland & Crabtree, 2009; Smith et al., 2011). Furthermore, chronic pain and overweight are often comorbid; many overweight
patients present with a pain syndrome, and vice versa (Wright et al., 2009; Stone & Broderick, 2012).
Pain has been described as a barrier to weight loss (Janke & Kozak, 2012) and a contributing factor to weight gain (Lake, Power & Cole, 2011), and overweight and obesity are thought to contribute to pain (Saber et al., 2008; Nilsen, Holtermann & Mork, 2011; Creamer & Hochberg, 1997; Lementowski & Zelicof, 2008).
Definitions
The Definitions of Overweight and Obesity
of 25.0-29.9 are classified as overweight, while individuals with a BMI of above 30.0 are classified as obese (CDC, 2012; World Health Organization [WHO] 2012).
Obesity is further divided into three classifications: I, II, and III, based on BMIs of 30.0-34.9, 35.0-39.9, and 40.0+, respectively (National Heart, Lung, and Blood Institute [NHLBI], 2013). Obese III, formerly commonly referred to as “morbid obesity,” is now referred to as “extreme obesity” (Ferrante, Piasecki, Ohman-Strickland & Crabtree, 2009). The disease risk relative to individuals of normal weight increases in patients who are overweight; it is considered high in Obesity I, very high in Obesity II, and extremely high in Obesity III (NHLBI, 2013).
Waist circumference and body fat distribution are also used as a framework for determining overweight. (Visscher and Seidell, 2001).
Other predictors of the health risks associated with excess weight include waist circumference, as well as other risk factors related to lifestyle and other diseases and conditions (CDC, 2012).
The Definition of Chronic Pain
Methods
Multiple professional domains, including the Centers for Disease Control and Prevention (CDC) and its National Center for Health Statistics (NCHS), the National Heart, Lung, and Blood Institute (NHLBI), the Mayo Clinic, the Cleveland Clinic, The International Association for the Study of Pain (IASP), the American Pain Society (APS), Gallup.com, the American Academy of Pain Medicine, and the peer-reviewed journals Obesity and The Journal of Pain were sourced for relevant publications.
Data collection was conducted via keyword searches of the search engine PubMed (MEDLINE) using combinations of the following keywords: “pain syndromes,” “chronic pain,” “back pain,” “headache,” “neck pain,” “joint pain,” “arthritis,”
“fibromyalgia,” “overweight,” “obesity,” “BMI,” “weight,” “weight loss,” and “primary care.” Repetitive searches were conducted until no new studies were revealed.
Many studies on the relationship between weight the following pain conditions: back pain, headache, and fibromyalgia were found, and six were selected based on pre-determined inclusion criteria. Each article was systematically critiqued and then
categorized into topic groups based on the type of chronic non-cancer pain condition studied.
written in a foreign language were excluded. Only human studies were included. Unpublished works were not eligible for review. Articles published within the past five years focusing on populations in the U.S. were included to help ensure consistency in prevalence rates. Throughout the paper, no restrictions were made on the publication dates of articles used to source information regarding definitions and other information which has not changed.
Results
Prevalences of Overweight and Obesity in Common Chronic Pain
Conditions
Results of the comprehensive literature are shown. Rates of overweight and obesity can be compared to the percent of adults over 20 years and older who are overweight and obese of 33.3% and 35.9%, respectively (NCHS, 2012).
Prevalences of overweight in chronic pain conditions in studies published in the United States in the past five years are shown in the tables below.
*Definitions: Overweight=BMI>25; Obese= BMI>30.
Overweight in Arthritis
Study Sample Characteristics Findings
Niu et al., 2009
N = 2,623
Mean age = 62.4
Average BMI = 30.4
Female = 60% Obese: 47.1
Ehrlich-Jones et al, 2011
N = 185 Mean age = 55
Female = 84%
Average BMI = 27.98
Overweight in Chronic Headache
Prevalences of Overweight and Obesity in Headache
Study Sample Characteristics Findings
Katsnelson et al.,
2009
N = 44 Mean age = 37.2
Female = 88.6%
Average BMI = 28.7
Obese: 37.2%
Overweight in Low Back Pain
Prevalences of Overweight and Obesity* in Low Back Pain
Study Sample
Characteristics
Findings
Young, Terrell, Whitham & Burge,
2011
N = 360 Mean age =
53.0 Female = 72.2%
Average BMI = 33.4
Prevalences of Overweight and Obesity in Fibromyalgia
Study Sample
Characteristics
Findings
Okifuji, Donaldson, Barck & Fine,
2010
N = 215 Mean age = 45
Female = 95%
Average BMI = 30.53 Overweight: 30%
Obese: 47% Kim, Luedtke, Vincent, Thompson &
Oh, 2012
N = 888 Mean age = 49 Female = 94.6%
Average BMI = 29.8 Overweight: 26.8%
Obese: 44.8%
Acute Pain Vs. Chronic Pain
The Differences Between Acute Pain and Chronic Pain
Acute pain is classified as a symptom, and chronic pain is considered a disease state (IOM, 20011; Grichnik & Ferrante, 1991; Henry, 2008; Woolf, 2010). Acute pain is caused by a disease or injury (Grichnik & Ferrante, 1991), and chronic pain is a
persists beyond the original injury, or exists in the absence of any injury or other known etiology (Cleveland Clinic, 2009).
Acute pain represents a proportional response to stimuli, whereas the nervous system of a chronic pain patient becomes “rewired for pain.” In other words, a
hypersensitization of the central nervous system causes a disproportionate response to stimuli (Institute of Medicine [IOM], 2011).
Acute pain is generally thought of as protective because it warns of the potential for tissue damage or further tissue damage (IOM, 2011), thereby promoting healing (Ward, 2002), whereas chronic pain serves no protective purpose (Costigan, Scholz & Woolf, 2009).
Occasionally, acute pain leads to chronic pain (Cleveland Clinic, 2009); however, the mechanism via which this occurs is not well understood (IOM, 2011).
Acute Pain Chronic Pain
Description Symptom Disease State
Etiology Known Known or unknown
Onset Rapid Slow
Duration Days, weeks, months Months, years
Time Self-limiting Unlimited
Reaction to Stimuli Proportional Disproportional
Purpose Protective No protective purpose
Background of the Problem: Overweight and Obesity
The Prevalence of Overweight and Obesity
In total, over 69% of adults in the U.S. are overweight or obese (NCHS, 2012); 33.3% and 35.9% of adults 20 years and older are overweight and obese, respectively. In 2007-2010, 35% of adults were classified as obese. Of these, 20% were classified as Obese I, 9% were Obese II, and 6% were Obese III (NCHS, 2012). Rates of obesity increased steadily in the 50 years leading up to 2007 (Parikh et al., 2007).
Recent reports show an apparent plateau in the rates of obesity (NCHS, 2012); however, obesity remains a leading public health problem: projections of the prevalence of obesity in 2030 are as high as 58% worldwide (Kelly, Yang, Chen, Reynolds & He, 2008), and 41% in the U.S. (Finkelstein et al, 2012).
The Public Health Significance of Overweight and Obesity
The mean per capita cost associated with obesity in the United States is $2,127 (Wee et al., 2005), and estimates of the healthcare associated costs due to obesity are as high as $190 billion (Cawley & Meyerhoefer, 2012). Conservative estimates of the time burden of overweight and obesity in primary care are 8% (Tsai, Abbo & Ogden,
2011).
The Impact on Overall Health and Comorbidities of Overweight and
Obesity
including diabetes, cancer, cardiovascular disease, asthma, gallbladder disease, osteoarthritis, and chronic back pain (Guh et al., 2009).
Physical functioning and psychosocial functioning are some of the aspects of quality of life which are negatively affected by obesity (Kolotkin, Meter & Williams, 2001).
Depression and overweight are comorbid; obesity increases the risk of depression, and vice versa (Luppino et al., 2010).
Under-Diagnosis and Under-Treatment of Overweight and Obesity
Despite the recommendation of the U.S. Preventative Task Force that physicians should screen all adults for obesity and refer their obese patients for treatment (U.S. Preventative Task Force [USPTF] 2003), fewer than half of all physicians record BMI regularly (Smith et al., 2011), and fewer than one-third of obese patients receive weight-loss counseling. Despite the rise in obesity rates since 1995, weight-weight-loss counseling has decreased by 46% (Kraschnewski et al., 2013).
The Causes and Risk Factors of Overweight and Obesity
An energy imbalance is the primary cause of overweight (Zimmerman, 2010), although many other contributing factors exist, such as the environmental influence on health, sleep deficits, and emotional factors (NHLBI, 2012).
Social networks and weight are correlated; a person is more likely to become
obese if he or she has a friend who is obese (Christakis & Fowler, 2007). Disparities
exist among racial and socio-economic groups (Zimmerman, 2010).
Preventing Overweight and Obesity
Regular exercise, a healthy diet, awareness of eating habits, and consistent monitoring of one's weight are several aspects of a healthy lifestyle which can help prevent obesity (Mayo Clinic, 2012).
The Treatment of Overweight and Obesity
Treatment for obesity is similar to prevention; common treatments for obesity are dietary changes, exercise, behavior change, weight loss medications, and in some cases, surgery. Common weight loss medications include Orlistat (xenical), Lorcaserin (belviq), Phentermine-topiramate (qsymia) and Phentermine (adipex-p, suprenza).
Weight loss surgery is typically recommended only in Obese III; surgery might be recommended for patients who are Obese II, but usually only if their obesity is
Background of the Problem: Chronic Pain
The Prevalence of Chronic Pain
The prevalence of chronic pain in the U.S. is estimated to be 30.7% of the population (Johannes, 2010); some estimates of the total number of U.S. adults experiencing chronic non-cancer pain are as high as 100 million (Gaskin & Richard, 2012).
This number is expected to rise, a forecast which is due, in part, to the population of Americans age 65 and older that is expected to reach 20% by 2030 (Chapman, et al., 2006), as well as the rising rates of obesity (IOM, 2011).
The Public Health Significance of Chronic Pain
Chronic pain is associated with higher use of health care services (Blyth, March, Brnabic, and Cousins, 2004). Costs associated with chronic pain include lost
productivity in the workplace, and excess health care expenses are estimated to be as high as 635 billion dollars per year (IOM, 2011).
The Impact on Overall Health and Comorbidities of Chronic Pain
Chronic pain has a deleterious impact on quality of life (McCarberg, Billington, 2006); it is a leading cause of disability (National Institutes of Health [NIH], 2010), and it affects many aspects of a person's life such as sleep, recreation, work, socialization, and overall enjoyment of life (Galer, Gianas & Jensen, 2000).
anxiety (Demyttenaere et al., 2007; McWilliams, Cox & Enns, 2003), depression (Arnow, et al., 2006; McDonald, 2008; McWilliams, Cox, & Enns, 2003; Bair, Robinson, Katon & Kroenke, 2003; U.S. Department of Health and Human Services [HHS], 2005; Ohayon & Scahtzberg, 2003; Demyttenaere et al., 2007), panic, general phobia, social phobia, agoraphobia, and post-traumatic stress disorder (McWilliams, Cox & Enns, 2003).
People with back pain experience higher rates of the “downhearted” feelings worthlessness, hopelessness, sadness, nervousness, and an increased perception of effort required for everyday tasks (Georgetown University Center on an Aging Society). Alcohol abuse is greater in people with back or neck pain than in those without it
(Demyttenaere et al., 2007).
The Under-Diagnosis and Under-Treatment of Chronic Pain
Chronic pain is under-diagnosed and under-reported (IOM, 2011). Reported rates of the under-treatment of pain range from 8% to 65% (Dandrea et al., 2008)
Common Chronic Pain Conditions
The Causes and Risk Factors of Chronic Pain
Overweight is associated with chronic pain. The rate of chronic pain tends to increase with increasing weight (Stone & Broderick, 2012), as well as severity of pain symptoms.
Causes of chronic pain include nerve damage (Van de Ven & Hsia, 2012), surgery, prior trauma (McGreevy, Bottros & Raja, 2011), syndromes and diseases such as fibromyalgia (Abeles, Solitar, Pillinger, and Abeles, 2008), shingles (McGreevy, Bottros & Raja, 2011), and arthritis (Lawrence et al., 2008), and overuse injuries (Kavanaugh & Yu, 2000).
People who have a bachelor's degree are less likely to experience back pain, neck pain, migraine, myofascial pain, or jaw pain, compared to adults who did not complete high school (Schiller, Lucas, Ward & Peregoy, 2012). The prevalence of pain is higher among the elderly, women, children, minorities (IOM, 2011), and lower-income groups (Brown, 2012).
Preventing Chronic Pain
Strategies for preventing acute pain from developing into chronic pain include pharmacology, physical therapy, pain psychology, and complementary and alternative medicine (CAM), and more invasive procedures.
Pharmacological options for preventing pain include non-steroidal
anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, serotonin-norepinephrine
reuptake inhibitors, opioids, local anesthetics, and certain agonists.
nerve stimulation, nerve catheters, interventional pain management, and genetics
therapies (McGreevy, Bottros & Raja, 2011).
Treating Chronic Pain
Treatment of chronic pain often begins with self-management, and can then take
place in multiple contexts, such as in primary care, with specialists, and at pain centers
(IOM, 2011).
A comprehensive, multimodal treatment approach is most effective compared to
treatment plans which focus on one aspect of care (D'Arcy, 2011). The IOM (2011)
recommends a coordinated and comprehensive interdisciplinary team approach to pain
treatment composed of physicians and nurses, mental health professionals, and
physical therapists, that ideally include a combination of pharmacology, psychology, and
rehabilitation, with the ultimate goals of reducing pain and improving quality of life.
Pharmacological treatments for chronic pain include a wide range of pain
medications; over-the counter medications, opioids, non-opioid drugs, non-steroidal
anti-inflammatory drugs (NSAIDs), including non-selective NSAIDs, as well as COX-2
selective inhibitors make up the wide range of pharmacological options available for
pain treatment.
Pain psychology is often used to prevent pain; cognitive behavioral therapy
(CBT) is one common form of pain psychology which has been shown to be effective in
both preventing and managing pain (Waters, McKee & Keefe 2007).
Rehabilitation is an important component of treating chronic pain. The Cleveland
biofeedback, vocational rehabilitation, drug dependency counseling, nutritional
counseling, family counseling, psychotherapy, relaxation, aquatics, tai chi, and yoga
(Cleveland Clinic 2013).
CAM treatments include the mind-body treatments biofeedback, hypnosis,
imagery, and relaxation therapy (Merck, 2009), as well as aromatherapy with lavender,
acupuncture and yoga (D'Arcy, 2011; Kim et al., 2007).
More invasive treatments include local electrical stimulation, brain stimulation,
and surgery (NINDS, 2013).
Exercise is important in helping prevent and manage chronic pain (Nilsen,
Holtermann & Mork, 2011; Freburger et al., 2009); however, patients in pain might have
trouble exercising due to strain on joints. In this case, pool exercise therapy can be a
good opportunity to introduce exercise while minimizing joint strain (D'Arcy, 2011).
Over-the-Counter Medications for Chronic Pain Treatment
Over the counter medications, such as aspirin, ibuprofen, and Tylenol are
available to treat pain, however, the doses available might not be as effective as
prescription-strength pain medications.
Opioids for Chronic Pain treatment
Trescot et al. (2008) found that opioids might be effective for short-term pain
relief of less than six months, but that evidence is limited for chronic opioid treatment.
Opioids also carry a risk for addiction, dependency, and diversion: 2.6 million
sedatives non-medically (Substance Abuse and Mental Health Services Administration
[SAMSHA], 2007).
Common contraindications for prescribing opioids to obese patients include
organ dysfunction, renal dysfunction, gastric bleeding, and other comorbidities common
among obese patients, such as diabetes (D'Arcy, 2011).
NSAIDs for Chronic Pain Treatment
NSAIDs block prostaglandin production which relieves both pain and
inflammation. NSAIDs include diclofenac, ibuprofen, ketoprofen, meloxicam, naproxen,
and oxaprozin (FDA, 2007). Potential side effects are allergic reaction, and long-trem
use might increase the risk of having a heart attack or a stroke.
COX-2 Selective Inhibitors for Chronic Pain Treatment
All NSAIDs have potential effects on the gastrointestinal system; however,
COX-2 inhibitors might carry a lower risk of such side effects. The only COX-COX-2 selective
inhibitor on the market is Celebrex (celecoxib).
Prevalence
The Prevalence of Chronic Pain in Overweight and Obesity
likely to report pain than their low-to-normal-weight counterparts. 21.8% of overweight individuals reported daily pain, compared to 18.9% of individuals of normal or lower-than-normal weight.
The difference in reporting of daily pain was higher for obese individuals, and highest for morbidly obese individuals, who were 25% more likely to report experiencing daily pain than individuals with a BMI of under 25.
Lake, Power, and Cole (2000) found that women with chronic back pain were more likely to gain weight than women without back pain; mean adjusted weight increase was almost 15 pounds.
The Relationship Between Chronic Pain and Weight
There are many ways in which chronic pain and overweight and obesity
contribute to one another (Wright et al., 2010). Furthermore, pain and overweight share many comorbidities and risk factors, such as depression and minority status (IOM, 2011; Wright et al., 2010; Grabner, 2012).
How Chronic Pain Contributes to Overweight and Obesity
Poor sleep, opioid use, lack of exercise, and poor eating habits are all behaviors associated with chronic pain which contribute to overweight.
sleep results in decreased sensitivity to insulin (Broussard, Ehrmann, Van Cauter, Tasali & Brady, 2012), and overeating (St-Onge et al., 2012), both of which contribute to
weight gain.
Sleep quality is also complicated by the use of opioids for chronic pain; opioids can provide enough pain relief to allow the otherwise restless pain patient to fall asleep (Brennan & Lieberman, 2009); however, opioids also alter sleep patterns (Dimsdale, Norman, DeJardin & Wallace MS, 2007). For example, despite having a side effect of drowsiness, morphine increases wakefulness and decreases the amount of time spent in the REM stage of sleep (Kay, Eisenstein & Jasinski, 1969).
Chronic pain can inhibit a person's ability or willingness to exercise (Stone & Broderick, 2012), and is associated with a lowered sense of self-efficacy in their ability to exercise (Janke & Kozak, 2012). Although exercise has an analgesic effect on
healthy individuals, it can exacerbate symptoms in patients with chronic pain, leading to “symptom flares” (Nijs, Kosek, Van Oosterwijck & Meeus, 2012), complicating the matter even further.
Chronic pain also contributes to inappropriate eating habits, such as eating for pleasure rather than hunger, overeating, binge eating, and emotional eating triggered by pain (Janke & Kozak, 2012), all of which contribute to overweight. Furthermore, sugar consumption has been shown to have an analgesic effect (Miller, Barr & Young, 1994), which might in turn encourage people in pain to consume “empty calories.”
How Overweight and Obesity Contribute to Chronic Pain
and multifaceted. Strain on the joints, inflammation, genetics, sleep loss, and comorbidities associated with overweight and obesity are all factors which might contribute to pain. Overweight and obese patients tend to exercise less than people of normal weight, a habit which increases their chance of developing a chronic pain condition (Nilsen, Holtermann & Mork, 2011).
Excess weight places additional pressure on the joints, which causes strain and contributes to joint pain (Creamer & Hochberg, 1997; Lementowski & Zelicof, 2008; D'Arcy, 2011). However, excess weight and its associated strain on the joints do not fully account for the link between pain and obesity (Stone & Broderick, 2012).
Decreased blood flow as a result of atherosclerosis, a condition that is common in obesity, might also contribute to back pain (D'Arcy, 2011). Inflammation as a
physiological response to extra fat stores could also play a role in contributing to pain (Stone & Broderick, 2012). There is also speculation that a genetic disposition towards obesity, depression, and chronic pain exists (Stone & Broderick, 2012).
Overweight and obese people report less sleep than their normal-weight counterparts (Vorona et al., 2005). Decreased sleep is associated with increased sensitivity to pain (Roehrs & Roth, 2005; Roehrs, Hyde, Blaisdell, Greenwald & Roth, 2006; Roehrs, Harris, Randall & Roth, 2012).
smoking has been shown to increase pain sensitivity (John et al., 2006).
Higher levels of leptin in obese individuals may contribute to pain sensitivity, while the lower levels of ghrelin might result in reduction of its antinociceptive effect in the body (Wood, Goodnight, Haig & Nasari, 2011).
Chronic Pain as the Result of Weight Gain
A study of 3,471 twins found that overweight twins were more likely than normal weight twins to suffer from low back pain and abdominal pain. Obese twins in the same study were more likely than normal weight twins to suffer from low back pain, tension headache, fibromyalgia, abdominal pain, and chronic widespread pain. After adjusting for depression and other factors, the associations weakened, but remained significant (Wright et al., 2009).
Weight loss as a result of laparascopic surgery has been shown to reduce pain in patients with fibromyalgia (Saber et al., 2008). However, another study evaluating the effects of a nonsurgical weight loss program among obese patients with low back pain revealed little improvement in low back pain (Roffey et al., 2011).
Current Recommendations in Primary Care
Findings from a study published by Marcus (2004) reveal that weight and
disability are correlated in chronic pain patients, and that “calculation of the BMI should
become a routine part of the screening evaluation for chronic pain patients, with
additional screening for disability and psychologic distress in patients with elevated
The Role of the Environment
The environment has an impact on health, particularly on weight. Availability and
access to healthy foods, and open spaces for recreation and exercise are important
factors. Economic issues, such as the prices of convenience foods compared to fresh
foods also impact the choices consumers make. Limited time also plays a role in the
ability to prepare healthier meals. People in lower-income brackets may be more
influenced to choose foods which contain more calories per dollar spent, as well as
requiring less time. These options also tend to be less nutritious.
High-calorie snack foods has also contributed to the increase in daily calorie
consumption of an estimated 145 calories per day, and marketing of these snack foods
has become a big business. Corn products, which are cheap to the consumer
(Zimmerman, 2010) are present in many snack foods and drinks. High fructose corn
syrup in particular is affordable, present in many foods, and high in calories.
The Barriers to Treatment
Patient, provider, and system level barriers exist in both treatment of overweight and chronic pain.
Patient-Level Barriers
Physician-level Barriers
Physician-level barriers include negative attitudes (Evans, Whitham, Trotter, & Filtz, 2011), lack of education and discomfort treating pain (O'Rorke et al., 2007).
Reluctance to discuss pain, unwarranted fears of addiction and side effects, gender and racial disparities, and the “hot-cold empathy gap” have also been described as barriers to treatment of chronic pain (Tai-Seale, Bolin, Bao & Street, 2011).
System-Level Barriers
Pain medicine is becoming an increasingly popular field; pain specialists typically come from the backgrounds of anesthesiology, physical and rehabilitative medicine, occupational medicine, psychiatry, and neurology; however, primary care backgrounds are under-represented compared to the burden placed on the primary care setting (IOM, 2011).
Access to pain treatment is a barrier, particularly among certain racial and ethnic
groups (Nguyen M, Ugarte C, Fuller I, Haas G & Portenoy, 2005; Green et al., 2003).
Discussion
Pain is a personal and complicated experience with many influences, including genetics, mental health, the presence of other medical conditions, the environment (IOM, 2011), behavioral tendencies, and psycho-physiological and cognitive responses (Keefe & Gill, 1986).
given to overweight patients in pain. However, these habits are often difficult for overweight patients in pain to implement for a variety of reasons. Exercise might be difficult due to chronic pain, excess strain on joints, and low self-efficacy. Emotional eating and depression might play a role in diet, and sleep deficiencies are common in both patients in pain and overweight patients. Furthermore, weight loss might not even result in reduced pain (D'Arcy, 2011).
Conclusions
In conclusion, there is a correlation between overweight and several common chronic pain conditions. Being over weight and in pain are conditions which influence one another and share many comorbidities.
Chronic pain and overweight develop over years. Their development is
influenced by multiple of factors, which are best addressed as part of a comprehensive model of care as they arise, and before either condition (chronic pain or overweight) are even present. Primary care physicians should screen all patients for overweight and obesity, and should screen all overweight and obese patients for chronic pain and mental health issues which might contribute to their weight problems.
Treatment is difficult due to a number of barriers. Overweight patients with a chronic pain condition require a specialized treatment approach. A multidisciplinary team and a medical home become even more important in this population. Each patient should have a medical home to aid in coordination of care, monitoring, and follow-up.
addressing both epidemics. Prevention programs for overweight should be given high priority.
Limitations
Many of the studies used for this paper did not analyze the causal relationship between lower back pain and weight, but were rather more exploratory in nature, exploring the prevalence of chronic pain in the overweight.
Other Considerations
Depression, age, and smoking are risk factors common to both pain and overweight. Addiction is also an issue which has relevance in both conditions.
Depression
The prevalence of depression in overweight and obese people is higher than in people of normal weight (McDonald, 2008; McWilliams, Cox, & Enns, 2003; Bair, Robinson, Katon & Kroenke, 2003; HHS, 2005; Ohayon & Scahtzberg, 2003; Demyttenaere et al., 2007; Marcus, 2004). Depression and pain are related in that people with depression are more likely to experience chronic pain at some point in the future (Arnow et al., 2006; McDonald, 2008).
pain conditions such as back pain, joint pain, and limb pain (Trivedi, 2004). Depressed patients who also had a chronic pain condition were depressed for nearly six months longer than depressed patients without a chronic pain condition (Ohayon & Schatzberg, 2003).
Serotonin and Norepinephrine are two neurotransmitters which are involved with
both pain and depression (Trivedi, 2004); Marks et al. (2009) explain that “serotonin and
norepinephrine have been implicated as principal mediators of endogenous analgesic
mechanisms in the descending pain pathways.” As a result, serotonin-norepinephrine
reuptake inhibitors might help treat both pain and depression in depressed patients who
have pain (Stahl 2002).
However, serotonin-norepinephrine reuptake inhibitors might not be an effective
treatment for all types of pain; serotonin-norepinephrine reuptake inhibitors have been
approved by the U.S. Food and Drug Administration (FDA) in the treatment of
fibromyalgia (FDA, 2008), but more evidence is needed for their efficacy in treating
osteoarthritis (Richards, Whittle & Buchbinder, 2011).
Age
Age is a risk factor for both chronic pain and obesity (Mayo Clinic, 2012; Rustøen
et al., 2005); many adults gain weight with age, and aging also increases the risk of
developing chronic diseases that might be associated with pain, such as osteoarthritis
(Rustøen et al., 2005).
Smoking
that smoking is associated with cartilage loss and higher pain reporting compared to non-smokers (Amin et al., 2007). Although smoking is considered a risk factor for obesity, smoking is associated with many other serious health conditions. Both former and current smokers report a higher perception of pain than non-smokers (John et al., 2006; Mitchell et al, 2011).
Areas for Further Research
Differences in Prevalence among Men and Women
This paper evaluated the relationship between overweight and obesity and chronic pain in adults; it would be worthwhile to further explore this relationship among each gender, as there might be a hormonal component to some forms of chronic pain, such as headache (Peterlin, Calhoun & Balzac, 2012). Furthermore, women have a higher prevalence of obesity than men (Ryan, Kushner 2012), and also have a higher prevalence of chronic pain (Croft, Blyth, van der Windt, 2010).
Causes of Pain Beyond Excess Weight on the Skeletal System
Addiction
Addiction and the reward system are both related to chronic pain and overweight; there might be an addictive component to eating, and pain treatment with opioids
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