April 5, 2023
Obesity and Pain Management: How to Treat Pain in Patients with Obesity
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Obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences. This definition given by the Obesity Medicine Association (OMA) identifies the biomechanical and psychosocial components of excess fat mass. Both of these components can play a vital role in pain perception.
Studies have shown an increased prevalence of chronic pain in patients living with obesity. A survey done in the United States from 2008 to 2010 showed a statistically significant association between increasing body mass index and reported rates of pain.
This correlation can be explained not only by the impact of excess fat causing biomechanical effects on musculoskeletal joints but also due to pro-inflammatory physiological processes occurring in obesity and the behavioral and psychological changes that occur in obesity. We often see increased levels of inflammatory markers like C-reactive protein (CRP) and interleukins in patients with Obesity.
Chronic pain leads to physical inactivity, leading to further weight gain. This vicious cycle has the potential to go on throughout the lifespan of a person living with chronic pain and obesity. Thus, obesity and regular pain combination lead to more significant deterioration in physical and psychosocial well-being than if it occurred in isolation.
The most common types of pain experienced by patients with obesity are musculoskeletal pain in axial and load-bearing body segments. This includes knee, foot, lower back, and shoulder pain. A study from a weight management clinic in Ireland showed that 91 percent of their patients had pain in one of the musculoskeletal sites. Neuropathic pain, chronic pelvic pain, abdominal pain, fibromyalgia, and headaches are often seen.
The presence of both obesity and chronic pain compounds the burden of each problem more than if it occurred alone. A patient with obesity and chronic pain will gradually have decreased physical function and endurance. Over the years, they are usually no longer able to participate in activities they used to, like playing with children/grandchildren, going on family vacations, and participating in sexual activity. This can easily open the door to depression. It is unsurprising to see patients living with obesity, chronic pain, and depression succumb to eating disorders in response to pain, further complicating the psychosocial, behavioral, and physiological implications of obesity and chronic pain.
Historically, the treatment offered for chronic pain and obesity has unfortunately been inadequate. Treatment should be provided in an unbiased, nonjudgmental way. There is an unmet need to address pain management in people living with obesity. A multidisciplinary team focused on pain management and weight loss is the answer.
Management of obesity should be carried out with four pillars: nutrition, physical activity, behavior, modification, and anti-obesity medications. There is emerging evidence about an anti-inflammatory diet, which can be explored, but a low-calorie, high-protein, high-fiber, nutritious, sustainable meal plan is recommended to treat obesity.
This should be handled by physicians very delicately. Inadequate pain management can be a barrier to a successful lifestyle modification plan. Similarly, insufficient obesity treatment can be a barrier to chronic pain management. Depression must be treated concomitantly with therapy or non-obesogenic anti-depressant medication, as untreated depression is another roadblock to engaging in healthful behaviors. For many patients, eating comfort food is a way of coping with pain. Behavioral therapy to change the relationship with food needs to be established in such patients.
Treating both obesity and chronic pain concomitantly can be challenging. Previous studies have shown that treatment outcomes in patients living with obesity and chronic pain are optimal. More studies wherein treatment of obesity, pain management, individualized physical activity, and behavioral therapy are initiated simultaneously as the first step should be carried out better to understand the relationship between obesity and chronic pain. Since patients with obesity and chronic pain commonly have depression, pain management should be done in a manner that patients do not become dependent on an opioid class of pain medications while making sure that the patient’s pain is adequately addressed.
Article written by:
Anila Chadha MD, DABOM
Family physician and Obesity Medicine physician at Dignity Health Medical Group, Bakersfield, California. Obesity Medicine Director, Mercy Weight Loss Surgery Program, Bakersfield, California.