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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 »

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Spinal Fusion Surgery in Severe Obesity

Lower back pain is not an uncommon finding in obese and very obese individuals. One surgical treatment option is to create a fusion between two or more vertebrae in an attempt to reduce pain by stopping the motion at the painful vertebral segment(s). In a paper just published in SPINE, Rahul Vaidya and colleagues from the Detroit Receiving Hospital and University Health Center, Detroit, report on their experience in a case series of 63 patients with a BMI of 30 or higher. Despite a higher surgical risk and a 45% greater chance of complications, obese and very obese patients showed significant improvement in visual analog scale for back and leg pain with some improvement in disability scores independent of the BMI of the patient. Thus, despite posing a greater challenge for the surgeon and slightly higher surgical risk, heavier patients stand to benefit as much from surgery as less obese patients. Incidentally, as with other types of orthopedic surgeries that improve mobility, no “spontaneous” weight loss was found to occur after spinal surgery. Important questions that remain to be answered include the role for pre-surgical weight loss and whether or not weight management will be made easier following surgery. AMS Edmonton, Alberta

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When Obesity Becomes a Headache

There is now ample evidence to suggest that headaches are more common in people with overweight and obesity than in people with normal weight. Thus, for example in a recent paper by Winter and colleagues from the University of Münster, Germany, published in Cephalalgia, reporting on a cross-sectional study of over 63,000 women, a BMI greater than 35 was associated with a 3-fold increased risk of daily migraine as well as increased risk of phonophobia and photophobia but decreased risk of a unilateral pain and aura. These findings on obesity and headaches were recently extended to kids, in a paper just published in Headache, Andrew Hershey and colleagues on behalf of the American Headache Society Pediatric Adolescent Section. These investigators reported data in 913 consecutive kids seen at 7 pediatric headache centers in the US. While the prevalence of overweight at initial visit did not significantly differ from the general pediatric population, the higher the BMI percentile, the greater the headache frequency and associated disability. Furthermore, any increase in BMI at 3- and 6-month follow-up was significantly correlated with a further increase in headache frequency. While the exact reasons for the link between obesity and headaches remains unclear, Marcelo Bigal and colleagues from Albert Einstein College of Medicine, Bronx, NY, USA have previously reviewed some of the putative mechanisms in an article published in Neurology. Firstly, several of the inflammatory mediators that are increased in obese individuals are important in migraine pathophysiology, including interleukins and calcitonin gene-related peptide (CGRP). Obesity is also a state of sympathetic activation, which may contribute to increase in headache frequency. Orexins modulate both pain and metabolism and dysfunction in the orexins pathways appears to be a risk factor for both conditions. Finally, conditions that are comorbid to both states (e.g., depression, sleep apnea) may also promote headaches. Whatever the exact mechanism, clinicians should be aware of the relationship between headaches and excess weight. Whether headaches promote obesity (i.e. treatment of headaches will prevent obesity) or whether obesity promotes headaches (i.e. treatment of obesity will reduce headaches) remains to be seen. AMS Edmonton, Alberta

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Pain in Older Obese Adults

BEST HEALTH BLOG FINALIST: The second round of voting is on – please vote AGAIN for your favourite health blog by clicking here Last night I gave a talk to General Practitioners at the Medical School in Victoria, BC (hosted by Dr. Brad Amson, General/Bariatric Surgeon). I spoke about the importance of carefully assessing patients for contributors and barriers to weight management. As blogged yesterday, pain is one of the most common issues in patients with excess weight and can be both a contributor and barrier to weight gain and severely obese patients appear at particular risk for pain catastrophizing. But how common is pain and how great is the incident risk in overweight and obese patients? This issue was addressed in a recent study by Noor Heim and colleagues from the VU University, Amsterdam, The Netherlands, published in OBESITY. This prospective study investigated the relationship between measured BMI and waist circumference with prevalent and incident pain in 2000 participants of the Longitudinal Aging Study Amsterdam, aged 55-85 years at baseline (1992-1993) and after after 3 years (N = 1,478) and 6 years (N = 1,271) of follow-up. The overall prevalence of pain was 33% at baseline and increased significantly with higher quartiles of BM. After adjustment for age, education, depression, smoking, physical activity, and chronic diseases, both men and women in the highest quartile of BMI were around twice as likely to present with pain than individuals in the lowest BMI quartile. Of the participants without pain at baseline, those in the highest quartile of BMI had a  2-fold increased odds for incident pain after 3 years of follow-up and around 2.5-fold after 6 years. The association with BMI was independent of waist circumference, suggesting that absolute weight rather than weight distribution was important for pain. This longitudinal study also answers the question whether or not pain in obesity is the chicken or the egg – it appears that obesity increases the risk for incident pain, rather than vice-versa. But what about weight loss and its effect on pain? This issue, interestingly, has not been widely studied and results have been inconsistent. Apart from the rather dramatic improvement in pain and mobility reported in surgical obesity treatment, the effect of non-pharmacological or pharmacological weight loss on pain incidence or progression is not clear (though my guess is that weight loss can’t hurt – no pun intended). Given the tendency… Read More »

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Pain Catastrophizing in Severe Obesity

BEST HEALTH BLOG FINALIST: The second round of voting is on – please vote AGAIN for your favourite health blog by clicking here Pain is one of the most common and debilitating problems in patients challenged by severe obesity. Not just a consequence of mechanical complications of obesity (osteoarthritis, back pain, plantar fasciitis, fibromyalgia, etc.), pain is often a key barrier to physical activity and thus weight management. In fact, excess pain can promote psychological (e.g. depression, anxiety) and behavioural (e.g. binge eating) factors that may further promote weight gain. This issue is of even more importance in patients who display the now well-described phenomenon of pain catastrophizing, or the maladaptive responses to pain (tendency to focus on and magnify pain sensations with an intense sense of unbearable suffering and helplessness) that plays an extremely important role in how pain is perceived and processed. Pain catastrophizing now accounts for a substantial proportion of pain-related disability. Studies in patients with fibromyalgia show that pain catastrophizing is associated with increased activity in brain areas related to anticipation of pain (medial frontal cortex, cerebellum), attention to pain (dorsal ACC, dorsolateral prefrontal cortex), emotional aspects of pain (claustrum, closely connected to amygdala) and motor control. Thus, catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain. In another recent study by Tamara Somers and colleagues from Duke University, morbidly obese patients with osteoarthritis (OA) reported higher levels of pain catastrophizing than OA patients in the overweight and obese category. The severely obese patients who engaged in a high level of pain catastrophizing reported having much more intense and unpleasant pain, higher levels of binge eating, lower self-efficacy for controlling their eating and lower weight-related quality of life. The relationship between pain catastrophizing and eating behaviour is of particular interest, as high-fat and high-sucrose foods have been shown to increase pain tolerance. Thus, binging on highly-palatable foods may be a compensatory response to emotional distress and pain. It is not difficult to see how patients can enter into a vicious cycle of pain, increased eating, weight gain, more pain, more eating, and so on. In routine practice, pain catastrophizing can be easily and reliably assessed with questionnaires like this one, which can be scored like this. Fortunately, pain catastrophizing is responsive to cognitive behavioural therapy, with clinically relevant improvements in upto 50% of individuals. I would have little doubt that failure to recognize and… Read More »

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