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Obesity and Fibromyalgia

Readers may recall previous posts on the relationship between obesity and fibromyalgia, a chronic condition characterised by widespread pain, muscle tenderness, and decreased pain threshold to pressure and other stimuli. Ursini and colleagues from Cantazaro, Italy, review the possible relationship between these two entities in a paper just published in Rheumatology International. The authors review the epidemiological data showing that fibromyalgia patients have higher prevalence of obesity (40%) and overweight (30%) and discuss several mechanisms that may explain ‘the hidden link’ between these two conditions. Proposed mechanisms include: impaired physical activity cognitive and sleep disturbances psychiatric comorbidity and depression thyroid dysfunction dysfunction of the GH/IGF-1 axis impairment of the endogenous opioid system However, as they also note: “…at this time is not possible to ascertain whether obesity is a cause or consequence of fibromyalgia.” Nevertheless, the authors do suggest that the ‘causal’ relationship between the two conditions is supported by observations that fibromyalgia severity can be improved by weight loss. This may be a good opportunity to remind readers that ‘causality’ is actually not always easy to demonstrate and it does take many levels of evidence to make any assumptions about causality convincing. These include: Biological plausibility (this is usually where basic science comes in) Time course (this requires longitudinal studies) Dose-effect relationship (can be seen in cross-sectional studies) Strength of association (epidemiology) Coherence (consistency across different studies) Add to this positive list the negative criterium that there must also be no ‘reasonable’ alternative explanations for the finding, and one may be able to eventually make a case for ‘causality’. Unfortunately, medicine is fraught with uncertainity, as data from different studies may be conflicting or inconclusive. This does not mean science is wrong – it just means that answers become more or less likely depending on the amount and quality of data and our understanding of the underlying biology. This is the difference between science and pseudoscience – when new data emerges, scientists change their opinion – pseudoscientists ignore it. Unfortunately, many prefer the ‘certainty’ of ignorance than the ‘uncertainty’ of true knowlegde. This is why the progress of the ‘pilgrim of science’ is such an exciting and ever-fascinating journey. I, for one, am glad that so many of my readers are willing to bear with me and join me on this expedition. AMS Edmonton, Alberta Ursini F, Naty S, & Grembiale RD (2011). Fibromyalgia and obesity: the hidden link.… Read More »

Obesity Compounds Pain in Fibromyalgia

As blogged before, overweight and obese patients frequently present with fibromyalgia, characterized by chronic pain, fatigue and depressed mood. A paper by Akiko Okifuji from the University of Utah, Salt Lake City, just published in the Journal of Pain, examines the relationship between fibromyalgia and obesity in pain, function, mood, and sleep. The study examines the impact of obesity on hyperalgesia, symptoms, physical abilities, and sleep in 215 fibromyalgia patients, who also underwent tender point examination, physical performance testing, and 7-day home sleep assessment. Almost 50% of participants were obese and an additional 30% were overweight. Obesity was positively related to greater tender point sensitivity, reduced physical strength and lower-body flexibility, shorter sleep duration, and greater restlessness during sleep. The results confirmed that obesity is a prevalent comorbidity of fibromyalgia and the authors suggest that weight management may need to be incorporated into treatments. In the paper, Okifuji and colleagues also discuss several potential mechanisms linking obesity to fibromyalgia including alterations in the endogenous opioid system, the endocrine system, and systemic inflammation, whereby adipose-tissue derived cytokines may enhance central sensitization. Clinicians should be aware of the relationship between excess weight and fibromyalgia, which can often pose an important contributor to weight gain and a major barrier to weight management. AMS Edmonton, Alberta Okifuji A, Donaldson GW, Barck L, & Fine PG (2010). Relationship Between Fibromyalgia and Obesity in Pain, Function, Mood, and Sleep. The journal of pain : official journal of the American Pain Society PMID: 20542742

Fibromyalgia and Nutrition

Recently, I blogged about the rather close association between excess weight and fibromyalgia. A paper by Laura-Isabel Arranz and colleagues from the University of Barcelona, Spain, published in the latest issue of Rheumatology International, reviews the role of nutritional factors in patients with fibromyalgia. While their analysis of the literature confirms the high prevalence of overweight and obesity in fibromyalgia patients and the rather sparse data suggesting that weight loss may improve symptoms, they also note that many patients with fibromyalgia may have other nutritional deficiencies which may or may not be related to this disorder. Rather limited evidence supports that notion that vegetarian diets may have some beneficial effects, perhaps due to an increase in antioxidant intake. They also note that although numerous food supplements have been studied, there is very little data to support their use in improving symptoms in patients with fibromyalgia. Clearly, the relationship between obesity, nutritional factors, and fibromyalgia warrants further study. AMS Edmonton, Alberta

Obesity and Fibromyalgia: a Painful Barrier to Weight Loss?

To anyone regularly dealing with overweight and obese patients, the frequent association between excess weight and chronic musculoskeletal pain is no secret. This association is particularly true for the rather enigmatic syndrome of fibromyalgia, characterised by the presence of generalized pain in muscle and joints, often associated with fatigue, poor sleep, and depression. Patients typically present with exquisite tenderness over discrete anatomical points, commonly referred to as tender points.  While there is still much debate around the exact etiology or even the exact diagnostic criteria (e.g. number of tender points) for fibromyalgia, there is no doubt that the presence of this syndrome can prove a major barrier to weight management. Indeed, it is not at all clear whether there may in fact be an etiological link between fibromyalgia and obesity. As outlined in a paper by Akiko Okifuji and colleagues from Salt Lake City, UT, published last year in Clinical Rheumatology, 70% of fibromyalgia patients in their study were overweight or obese and presented with elevated levels of IL-6, catecholamines, cortisol, and CRP, all of which are common findings in obese patients. Furthermore, the patients with fibromyalgia, as do obese patients, presented with reduced sleep duration and efficiency. Based on these commonalities, Okifuji and colleagues concluded that excess weight and obesity may well play a role in fibromyalgia and related dysfunction.  Interestingly, in 2008, Alan Saber and colleagues published an article in Obesity Surgery describing a significant improvement in pain score and points of tenderness in patients with fibromyalgia who underwent laparoscopic Roux-en-Y gastric bypass surgery. Based on these findings, the authors suggested that weight loss may be an important treatment modality for severely obese patients with this syndrome. Whether or not less drastic approaches to weight management can provide benefits remains to be seen. Nevertheless, there have been reports of limited response to education, exercise, and psychological interventions. Thus, currently accepted non-pharmacological treatments for fibromyalgia remain rather limited. Recently, a Cochrane review concluded that duloxetine is efficacious for treating pain in fibromyalgia and another systematic review found evidence that gabapentin and pregabalin can also reduce pain in these patients.  Nevertheless, fibromyalgia continues to be a common but largely undertreated problem in overweight and obese patients and can often pose a significant barrier to increasing physical activity or modifying ingestive behaviour.  As blogged before, assessment for muskuloskeletal pain should be a regular and essential feature of any assessment for overweight and obesity.  I very much look… Read More »

Factors That Affect Physical Activity

Continuing with citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, we now turn to the some of the factors that can affect physical activity. Similar to the factors that can affect ingestive behaviour, there are a host of factors that can significantly affect physical activity: Socio‐cultural factors A wide range of socio‐cultural determinants of physical activity exist. These range from factors related to the built environment (e.g. urban sprawl, walkability, street connectivity), neighbourhood safety, social networks, and public transportation to socioeconomic limitations as well as customs and beliefs that can influence vocational or recreational physical activity. For example, being promoted from a physically active outdoor job to a sedentary indoor job, moving from a dense urban location to a rural or suburban residence, immigration to a Western country, pregnancy and change in familial status or time constraints can all promote sedentariness and increase the risk of weight gain. Indentifying and addressing the socio‐cultural barriers to physical activity can be a key to successful weight management. Patients facing significant socio‐cultural barriers to activity may specifically benefit from counselling by an occupational and/or recreational therapist. Biomedical factors Numerous medical conditions can lead to a reduction in or inability to engage in physical activity. These include musculoskeletal pain or immobility resulting from injury, osteoarthritis or fibromyalgia as well as any other condition that can affect physical performance such as cardiorespiratory disease, obstructive sleep apnoea, chronic fatigue, stroke or urinary incontinence. Alleviating these factors and thereby reducing immobility may be the first step in addressing weight management in these patients. Given the predominant role of musculoskeletal disorders and pain as a barrier to mobility and physical activity, these patients may benefit most from physiotherapeutic interventions and pain management. Psychological factors and mental health Lack of motivation, low energy levels and disinterest in exercise (especially in a previously active individual) can be a symptom of depression. Social anxiety disorder, agarophobia, sleep disorders or substance abuse can all affect physical activity levels. Body image issues and self‐efficacy can likewise pose important psychological barriers that may require specific professional counselling and intervention to promote a more active lifestyle. Medications Although published research on this issue is limited, it is reasonable to assume that medications, which reduce energy levels, promote drowsiness, impair coordination or limit cardiorespiratory function can pose significant barriers to physical activity. Now that we have discussed why it is… Read More »