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Bariatric Surgery For Migraines?

Among the many aches and pains commonly associated with excess weight, the increased prevalence and severity of migraines in patients with obesity is perhaps the least well known. Not only do migraines appear to be more common in patients with excess weight but there is also evidence that people with severe obesity are likely to have more severe migraines than individuals with normal weight. There are a number of plausible psychological and physiological mechanisms that could explain this relationship. The former include the finding that pathological pain processing, catastrophising and sensitivity has been associated with excess weight. The latter is supported by recent evidence that pro-inflammatory molecules that are increased in obese individuals can act as pain mediators in neurovascular inflammation. These finding certainly raise the question whether weight loss can reduce the frequency and/or intensity of migraines. This question was now addressed by Dale Bond and colleagues from Providence, Rhode Island, in a paper just published in NEUROLOGY. The researchers prospectively assessed 24 patients (88% female, BMI 47) who had migraine according to the ID-Migraine screener before and 6 months after bariatric surgery. Post-surgical weight loss was associated with a significant reduction in number of headache days from 11 to 7 in the 90 days preceding each assessment. Patients, who lost the most weight, also had the greatest odds of experiencing a more than 50% reduction in headache days. Furthermore, the number of patients reporting moderate to severe disability due to migraines decreased from 12 (50.0%) before surgery to 3 (12.5%) after surgery. While patients also reported significant improvement in depression (average PHQ-9 scores reduced from 8.8 to 4.3), the changes in mood were not predictive of the improvements in migraines. This study certainly supports the hypothesis that migraine frequency and severity in severely obese patients reduces with surgical weight loss. On the other hand, before jumping to overly enthusiastic conclusions, it may be prudent to note that this study did not assess or discuss the possibility that the lifestyle changes associated with surgery may simply have reduced exposure to many of the nutritional and lifestyle triggers of migraines (e.g. certain foods such as fruits, onions, chocolate, nuts, cheese, sugar, caffeine, alcohol or red wine as well as stress or physical exertion). I guess it would take a prospective trial with careful assessment of these migraine triggers (or at least a control group of weight-stable patients who make the same dietary… Read More »

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Would Reducing Obesity Save Thousands of Knees?

On most days, our obesity clinic could easily be confused with an orthopedic clinic given the sheer number of patients who present with severe pains in their backs, knees, hips, and ankles – often to the point of immobility. It turns out (perhaps not surprisingly) that today, obesity and knee osteoarthritis are among the most frequent chronic conditions affecting Americans aged 50 to 84 years – my guess is that these conditions are no less frequent among Canadians. Given the high prevalence of both obesity and knee osteoarthritis and their very significant impact on quality of life, Losina and a team of researchers from Harvard, Boston University, Chapel Hill, Yale and the University of Sydney undertook the rather momentous task of estimating the impact of these conditions on morbidity and mortality in older Americans. Their results were now published in the Annals of Internal Medicine. The researchers based their analyses on U.S. Census and national obesity data with estimated prevalence of symptomatic knee osteoarthritis, whereby they assigned the US population aged 50 to 84 years to four subpopulations: nonobese without knee osteoarthritis (reference group), nonobese with knee osteoarthritis, obese without knee osteoarthritis, and obese with knee osteoarthritis. They then used a computer simulation model (The Osteoarthritis Policy Model) to estimate quality-adjusted life-year losses due to knee osteoarthritis and obesity and to determine health benefits of reducing obesity prevalence to levels observed a decade ago. It turns out that the estimated total losses of per-person quality-adjusted life-years ranged from around 2 years in nonobese persons with knee osteoarthritis to about 3.5 years for persons affected by both conditions. Although these numbers may not sound shocking, they actually represent 10% to 25% of the remaining quality-adjusted survival of persons aged 50 to 84 years. When calculated for the entire US population in that age range, this amounts to a staggering 86 million quality-adjusted lost to these conditions. The researchers also calculate that reversing obesity prevalence to levels seen 10 years ago would avert just over 110,000 total knee replacements – so reducing obesity (even to where it was just 10 years ago) could indeed save a substantial number of knees. What the paper of course does not disclose is how exactly such a reversal in obesity rates could possibly be achieved. Clearly, the impact of weight loss on knee (and other) pain that we see in our clinic is often dramatic, but achieving weight… Read More »

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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

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No Pain No Gain?

Yesterday, I presented Grand Rounds at the Holy Cross Pain Centre in Calgary. As regular readers will recall, pain is a common consequence and/or cause of weight gain and very often a major barrier to weight management. Not only is obesity commonly associated with conditions such as fibromyalgia, back pain, osteoarthritis, or plantar fasciitis but also migraines and other forms of headaches. In the same manner that obesity is a complex syndrome that has a multitude of psychosocial and biological determinants, so is chronic pain. It was therefore not surprising to see that many of the principles of interdisciplinary pain management used at the Holy Cross Pain Centre are not very different from the principles we use in the Weight Wise program. The team at the Pain Centre is fortunate to have the support of physio- and occupational therapists, nurses, psychologists, pharmacists, dietitians and other allied health professionals as well as a wide range of physician consultants working at their centre. This complement of health professional is indeed very similar to what we have in our obesity clinic. There are other important similarities: managing patient expectations, emphasis on self-management, focus on functional goals, attrition rates, and other characteristics of chronic disease management programs. As I have often blogged, obesity is not really different – it just takes the same approach and resources to manage as other chronic conditions – no more, but also no less! AMS Calgary, Alberta

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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

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