164 | What Actually Helps Chronic Pain?

Success to me and what I tell patients is 30% or greater improvement, if not higher, to justify them taking a supplement.

Welcome back to the Exam Room Nutrition Podcast. I'm Colleen, a PA and dietitian. And if you've been hanging with me through my summer school episodes, I hope you enjoyed them. But I am so excited to be back with brand new conversations. Last month I spoke at the PA Mom's Women's Medical Summit, and I got a bunch of questions about using nutrition and supplements for pain management. And I'll be honest, this is not really my wheelhouse, so I'm really excited to chat with an expert in this area today. Chelsea Hoffman is a PA and registered dietitian specializing in pain medicine at Mail Clinic. And today we're talking about what nutrition can realistically do for chronic pain, where supplements fit in, and which ones Chelsea recommends because they actually have evidence behind them. This is such a good conversation for anyone who's ever had a patient ask, is there anything natural that I can take from my pain? So grab your coffee or drive safe and enjoy my conversation with Chelsea. Chelsea, thank you so much for coming onto my podcast. I'm super excited to talk to another unicorn like myself. We're both RDPAs. So thank you so much for being here. Welcome to the show.

Thank you so much for having me. I admire your work from afar as we've connected on these social media platforms. And I'm really excited to be here having this conversation with you.

Yeah, when we connected on LinkedIn and we were talking about, okay, what topic should we discuss? We landed on supplements, which I love, but I've covered a lot on the podcast. So I really love the lens that we're going to discuss today. And we're going to talk about patients living with chronic pain. And they're so often searching for anything that might provide them relief. So I'm curious, I'd love to start the conversation by understanding where nutrition realistically fits into the patient's pain management plan. And then maybe where do we need to be careful not to like overpromise complete symptom relief with a nutrition plan?

So with the patients that I see in interventional pain medicine, I always like to start with the basics, the conservative types of things that we can be doing. And that really brings in lifestyle medicine, holistic medicine. And I always tell patients we have to take care of first things first, right? In interventional pain medicine, I can always come up with some type of injection or procedure that might be helpful. But if we're really not taking care of ourselves as humans and doing the basics, it doesn't really matter all these other medications or things that I might recommend. We need to be doing the first things first. And I often find out that before we even move into conversations about supplements or specific foods or macro or micronutrients, really just that overall dietary pattern kind of needs some tweaking or some work first. So I find that that's the first starting place for individuals.

But inflammation has sort of become like a catch-all explanation for like pain online. And so I would love if you can teach us how you explain the relationship between food inflammation and chronic pain.

That's a great question. And it's really, really complicated, right? So when I discuss inflammation with patients, I think we really have to kind of boil it down and make it practical for them and just really get down to the basics and talk to them about foods that are processed or packaged or hyperpalatable and how that impacts our bodies in terms of our blood sugar, in terms of our cholesterol and our heart health, right? Because we know some of those things are inflammatory from a cardiovascular standpoint or a glucose control standpoint. And so I kind of start there. And it's maybe not so much about inflammation in any one specific joint. It's taking care of our bodies in terms of being here for the long run to protect our health and longevity and our functionality as humans. So I speak about it more in broad terms and not that we're trying to aim at just their knee pain or just their shoulder pain, which most certainly may have an inflammatory component to it as well.

I really like how you differentiate between the two because I don't think patients really think about it like that. There could be chronic systemic inflammation, but definitely diet can help. And then you're having, you know, localized inflammation, like you had mentioned in your in your knee joints or your shoulder or something like that. And I'm sure the next question patients ask is like, well, should I go on an anti-inflammatory diet? So I'm curious, how do you answer that question about an anti-inflammatory diet?

So the diet that I talk to patients about the most that has been around for decades and that I personally feel has the strongest evidence supporting it, not just necessarily for chronic pain, but also for improved cardiovascular health, improved mental health, improved sleep, overall quality of life scores, and pain reduction. That's going to be the Mediterranean diet. And so it has withstood the test of time. It has the largest, most robust evidence base supporting it. And I always tell patients that and providers that the good news is that a Mediterranean diet is inherently anti-inflammatory. And of course, I work at Mayo Clinic and we have our own spin-off of the Mediterranean diet that is known as the Mayo Clinic diet. They're all sort of grounded in the same foundational principles or elements. And it's those pieces that are the most important.

Okay. Now you teased it, but I got to know what are those foundational elements that you really want to prioritize with your patients?

Absolutely. So again, it's getting back to the basics, right? And as uh advanced practice providers, as registered dietitians, it's going through with our patients six or more servings of fruits and vegetables daily, focusing on whole grains and teaching them what is a whole grain food. How do we identify it? What do we need to look at on the package label if we are purchasing a packaged product? We talk about fiber. We talk about using olive oil as our primary cooking oil of choice. We talk about ways to incorporate more seafood if that's something that they would like to include in their diet to get those omega-3 heart healthy fats. Uh, we talk about including nuts for their polyunsaturated fats and their heart health benefits and minimizing, again, right, the processed, packaged foods, the hyper palatable foods. Yeah.

Okay. I know my listeners, listeners are like, but Colleen, you said we're going to talk about supplements for pain management. And I think the having that conversation with the patient is really important because they often are just so eager to find a solution. How do you have this conversation with patients? Like the importance of your diet and the foods that you're eating, while maybe in the next visit or in the future, we might add on supplements. Uh, how do you tease out the two?

Yeah. So I actually have like, uh, do you remember the United States Dietary Guidelines for Americans, the old school pyramid, right? And so I have modified that pyramid for patients who are suffering from chronic pain, potentially inflammation. And when we're having these dietary conversations, the base of the pyramid is the overall dietary pattern. And I explained that that is what matters the most. It's what we do day in and day out. That is what is gonna move the dial the most for them from a pain, a longevity, a functionality standpoint. Second layer of the pyramid is gonna be specific foods, macro, micronutrients, many of which are encompassed in that uh bottom of the pyramid if they're following a Mediterranean style diet. And then the tippy top of the pyramid is the supplements. So we're not gonna go up there and talk about it until those lower two layers of that pyramid have been discussed and dialed in first. And so I think it's just being really frank and honest and explaining that with them. We're gonna start here. We're gonna slowly work up. And if we get to supplements, then we get there. But if not, you know, we're gonna stay down here until these things are addressed first.

Yeah, I love that image that you used of the pyramid. I think it's easy to understand for patients. I also think it's easy and quick to teach. I would love to hear what are the most common supplements on the market right now advertised to those suffering from chronic pain. And to piggyback that, what does the evidence say about their actual benefit?

I think if you, if we do like a Google search right now and see once what the top ones are that are up there, it'd be interesting to know whether or not those actually reflect the evidence that's out there. So those might be two different things. So I'm gonna speak to the evidence side of it. So every year we do a clinical updates and pain medicine course here at Mayo Clinic, and I give the nutrition interventions for chronic pain talk. And so every single year I update my slides to take a look at what is the latest and greatest evidence base that is supporting these different supplements that I'm gonna talk about. And there's different ways that we can kind of break this down and I'll explain that. But let's say, for example, if we are talking about neuropathic pain for a minute. So burning, tingling, prickling, shooting, electrical shock-like type of pain. For people that have nerve pain conditions, often alphalopoic acid will come out on top because it has pretty good evidence for painful diabetic peripheral neuropathy, which is quite common. Acetyl-L-carnitine, that's another one that tends to come out on top for the same indication, painful diabetic peripheral neuropathy, and sometimes for other nerve conditions. So set those aside because those are nerve pain specific. If we're talking about more general, sort of like musculoskeletal pain, which that's probably the bulk of the population is looking for those types of supplements. Those are going to be things like turmeric or curcumin, glucosamine chondroitin, omega-3s, collagen is a popular one. I hear a lot of hype about magnesium. So that's out there. Vitamin D. And there's one that's known as sort of like a mixed supplement, meaning that it can be used for neuropathic or musculoskeletal pain or both. And that one's kind of a mouthful. It is PEA or palmatyl ethanolamide. And it's really hard to say, so we'll just stick with PEA. But that one's a good one for mixed pain conditions.

Okay. That was a lot. That was a lot. How do you choose, let's say, for lack of a better word, or how do you help the patient identify which one? Because we also have to think of access cost, like these all cost something. So uh bring us into your mind in sort of your decision-making algorithm.

Absolutely. I completely take an algorithmic approach to this and I individualize it for every patient that's in front of me. So, first of all, I want to give the disclaimer that we're assuming that patients have their overall dietary pattern dialed in, right? Okay. Because I'm not even going to talk to them about supplements if they haven't really dialed in their overall dietary pattern first. And then from there, sure, we're having this conversation that you and I are having now about supplements. So for me, I look at things like are they on any medications that would interact with a supplement? The one that comes up the most common is going to be blood thinning medications, with which many people are taking. And many supplements have antiplatelet properties. So it can elevate a patient's bleeding risk. So that's one thing that I'm paying attention to as I'm trying to decide which supplement may or may not be appropriate for them. Another place that I really give a lot of attention to is whether or not they have an active treatment plan in place for something like cancer. So anytime someone is on a chemotherapy program, our oncology teams are really particular about what medications and supplements patients are taking. And so to me, that might not be the best time to be experimenting with some of these supplements for chronic pain and for inflammation. And so again, we can kind of set those two aside, but those are big things that I'm looking for right off the bat. So I kind of work through: is their pain neuropathic? Is it musculoskeletal? Is it both? And then from there, are they on a blood thinner? Yes or no. Are they on some sort of active oncologic treatment plan? Yes or no. From there, I sort of funnel it down into what might be the most appropriate for them. I'm not a big fan of the combined supplements that are on the market today. I won't name stores or brand names here, but you know the ones I'm talking about, joint health types of complexes. I think they mix too many ingredients into one thing. And my worry is that when people do have supplement-associated side effects, I as a practitioner want to be able to identify what they're reacting to, right? So we can document it. So I always give that counseling that if we can find single agent supplements where it's just the one supplement that we are supplementing with. And if it's been third-party purity tested, even better. But that's what I want to focus on. And I want to give it a real good trial, probably about 12 weeks before we say yes or no, it is or isn't working, and having really clearly defined goals with patients about what does success look like at the end of this trial. Because I'm not a fan of just layering on all these supplements and getting into the realm of polypharmacy, drug drug, or drug supplement interactions. The whole goal of this is to be intentional, right? So that was a lot again there, but hopefully that helps answer your question in a thoughtful way.

Yeah, super helpful. I want to summarize and just kind of talk loud what I heard you say. So I love how you gave us that caveat of before even recommending a supplement. And I know my dietitians are going to be like, yes, thank you. You've got to get the nutrition issues dialed in. So I love, Chelsea, that you start there. I also really love how you mentioned your oncology patients. And that is a specialized topic in and of itself. I actually want to call out a previous podcast episode I did with an oncology dietitian, and we talked about supplements in that specific population. So if you're curious about that, that would be a great episode to listen after this. It's episode 75. Are your patients taking too many supplements and don't even know it? Really great talking points in that episode. I also wanted to kind of linger on you mentioning um once they start that you kind of use it as a trial. And you had mentioned like a 12 weeks or so. Yes. What are you looking for in those 12 weeks?

Yeah. So I always tell patients that when I look at supplement research that is out there, the reason that I came up with 12 weeks is because on average, when I looked at all of the studies for those supplements that I rattled off earlier, the clinical trial of that supplement study sometimes landed somewhere between, I would say, six to 12 weeks on average, with most of the supplement studies being on the higher duration of a trial. And so for a while, I was kind of giving different trial durations based upon the supplement that I was recommending. And then I was like, you know what, this is just too confusing. And so I'm just going to make it kind of 12 weeks across the board because that's what really is the most common in the research. From there, we have to decide what is success. Success to me and what I tell patients is 30% or greater improvement. And then the question is, where did that 30% come from? It came from the fact that in you know placebo-controlled trials, when someone's getting like a sugar pill, often success with that is defined as 30%. So if I know that patients could possibly get 30% improvement with a placebo, I want to see at least that, right? If not higher, to justify them taking a supplement, metabolizing that in their body, spending their money, their time, their energy, their effort in purchasing it. So that is where 30% or greater came from. Because we want to see at least placebo effect, hopefully more than that, of course. Because I think once you explain to someone that we're looking for at least 30% improvement, hopefully a bit more. When they hear 30%, they're like, wait, what? I'm only going to potentially get 30% improvement. And then when you explain why 30% as I did, they're like, okay, that makes sense. But I think it really brings to light for them, it makes it really crystal clear that there's no magic bullet here. I wish there was. I always tell people if, you know, if we had invented something like that, uh, I'd probably be on a yacht somewhere right now and I wouldn't be working as many hours a day as I do, right? But it doesn't exist. And so 30% or greater is the goal. And so just being really clear about that from the get-go, I think is really helpful for people. And it's not just a numerical pain reduction that I want to see. I like objective functional goals. And so I want to hear from patients when they come back. We're going to document together at that first visit what are their functional goals, what are their, you know, numerical pain or otherwise goals. And we're circle back to those at the end of the trial and ask ourselves, did we make improvement on any of these? Yes or no? And that will help us understand is the supplement worth keeping? Or do we discontinue and move on to something else?

That's really helpful. Now, in choosing one, do you start like one at a time and add on, remove, or do you are there ever situations where you maybe start them on three different supplements at a time?

Usually not. Usually not. It's one at a time. So that we can be really, I always say we're going to be a scientist about this. And we are going to do some experiments. And these experiments aren't going to be forever. They're going to be for a really defined period of time. And we have these, again, objective data that we're trying to find during each of these trials and figure out what works for them. And there's just so many people that I think have allergies and intolerances and side effects to medications and supplements that it makes sense to do it in a linear fashion and one at a time and be intentional so that if something does pop up, we we know what it's from.

Now, going back to the list that you provided of the ones that are, you know, studied in literature and are safe to recommend. Do you have like a top one or two that you're like, oh, I'm always starting with this one?

Yeah, that's a great question. For nerve pain, alpha lopoic acid is the one that I tend to go to the most. And part of that is because it can be purchased, I think, in you know, 300 or 600 milligram capsules, and people can start on the lower end. As they go through that 12 weeks, they can work up to the max recommended dose of that. And it's just a nice one to start with for nerve pain. I haven't had a lot of individuals come back and tell me that they've had any side effects with it. So that's part of this too, right? Is anecdotally what have I experienced with patients and what have they tolerated? So that's probably where I tend to kind of get my go-to's. So I would say for nerve pain, alphalopoic acid. For musculoskeletal pain, if it's knee or if it's hips, so knee osteoarthritis or hip osteoarthritis, I'm definitely thinking about glucosamine, chondroitin, collagen, turmeric, or curcumin. An argument could be made for omega-3s as well, but almost all of those have really good evidence for knee and hip osteoarthritis. That just tends to be where they've studied it the most. And I want to make sure that you and I tap on the fact too that if I suspect that there's some sort of underlying deficiency present after we've had a chance to assess the diet. So, for example, if I am hearing more like really vague like muscle tremors or spasms or cramping or something, I'm like, geez, it are they magnesium deficient or what's going on here? I'm gonna check that or I'm gonna oftentimes I don't check it, frankly, in pain medicine because it's a little bit outside of my scope, but I will tell them you should ask your primary care provider the next time you get labs if they can check your magnesium. Similarly, if I think that it might be bony associated pain and I look through their history and see that they haven't had their vitamin D checked in like a decade or longer. Maybe the next time they go in for their next preventative exam and they're going to be getting annual lab work anyways, could they throw a vitamin D on there too? And let's check that because I think that those are things that could be missed. We can document deficiency. We know how to treat it. And we can again objectively circle back and say, did treatment make an improvement? Yes or no? But I really do think when there is potentially an underlying nutritional deficiency, it's important to give that time and attention and document it and treat it appropriately before we sort of willy-nilly start grabbing at these supplements.

Okay, you mentioned turmeric, and I actually want to pause on that for a moment because it got me thinking, how are we recommending patients take it? Because I have heard of other methods like in tea. Is it as effective? Is this a tablet? What is the formulation that you're recommending for turmeric?

Yeah. So when I talk to patients about supplements, I am talking about like tablet or capsule formulations of those. And that's because honestly, I would have to do some at-home experimentation to find out whether or not we can truly get to the goal dose of you know, curcumin, which is the active component of the turmeric. Can we get to that dose through curry and tea alone and actually from a gastrointestinal standpoint tolerate it? I don't know the answer to that, truthfully. I do know that culturally there are some cultures that that's a huge staple in their diet and it's in a lot of things that they consume throughout the day. But I think for general immune health and things like that, if that's something that people enjoy and it's flavorful and it's comforting and good to them, or it's part of their culture, then go you. Absolutely. You should include those things if it feels good to you.

Yeah, I think that's helpful. And Correct me if I'm wrong, but tablets are usually what's studied in the literature, correct?

So that's a great question. We I'll just give one example specific to the area that I work in. We actually did a scoping review looking at supplements that had been helpful for spine pain. Okay. And I want to say B vitamins and vitamin D had the most supporting evidence behind them. But I had to point out in the limitations of that study that there was so much heterogeneity in the formulation of vitamin D, for example, that was used across the studies that I looked at. Some of them, like you mentioned, what formulation? Some of them, it was like a tincture or a capsule or a liquid. And the guidance that the patients were given in each study of when to take it and how to take it, meaning, like, was it with a meal? Was it with milk? Was it taken on an empty stomach? Was it in the morning? Was it in the midday at night? It was so variable across the studies that it was really difficult to draw meaningful conclusions from that. And I find that that tends to be the case in many supplement-related studies. We're not comparing apples to apples, which makes it really hard for practitioners to draw meaningful takeaways and to then translate that science to our patients. So for ease of dosing, I say tablets or capsules, but in the research out there, it really is across the board.

Yeah. Now you also mentioned something that I wanted to pick your brain on was timing of day and or like what else do they take it with? So I'm curious, what is your instruction or your education for your patient if you have them taking XYZ supplement? When, with what, and what about other medications that they might be taking?

Ooh, that's a great question. I usually will ask them to look with me at what the directions are on the back of the bottle. How is it meant to be taken? Because I'm sure every supplement company, every formulation is formulated a little bit differently. I do tend to find, and again, this is where individualized medicine, right? Patient-centered care comes into play. Some people just don't do well taking supplements on an empty stomach. I don't know about you, but if I take even like a multivitamin on an empty stomach, I don't always feel the best. So for those folks, they might need a little bit of food, even if it's just a cracker or something small in their stomach before they're going to be taking this supplement. And then of course, if they're on something like a thyroid medicine or something that requires fasting for a certain amount of time, you know, leavoth aroxin before you go taking some sort of supplement. I'm always very considerate of that as well.

I wanted to um kind of summarize what you've talked about a little bit about how and when to choose a supplement because you had an excellent LinkedIn post in which you posed like five questions that you should be considering before recommending a supplement. So I just wanted to call those out for you guys listening so you can kind of like think through what we've talked about today. The first one was can you meet this need through your diet? The second is what specific goal are you trying to achieve? The third is how will we define and measure success? Fourth is could this supplement interact with your medications or medical conditions? And the last one is is there evidence of an underlying deficiency that actually needs to be corrected first? Love this checklist. And I think it's a great framework as clinicians for us to use. So I want to back up to the medical conditions because we talked a little bit about it, some of the medications as well. And I wanted to kind of tease out any more that you might think would be like a red flag for a clinician to maybe pause on recommending a supplement. You've already mentioned our oncology patients and you've already mentioned blood thinners. Are there any other medical conditions or medications that we should be a little bit more cautious with?

When I talk to providers about smart supplementation, I do call out the patient populations of those who are pregnant or breastfeeding as well. To me, again, they that that group, that population has been excluded from many medical research studies, including supplement studies, and for good reason. There's a developing fetus in utero. We then have uh, you know, the breast milk and what is being transferred there. So that's again a place where I do not like to experiment with supplements for chronic pain and for inflammation. I would rather wait to a more ideal time because we don't know the risk. From there, I think as providers, it's our duty to be diligent if we're going to recommend anyone's supplement to take a look at what a patient's allergies and intolerances are. And I don't know about you, but in the electronic medical record, I see quite a few people that have a lengthy allergy or intolerance list. When I go through that, sometimes I will catch things that might be in a supplement that I'm thinking about. And I'm like, oh, nope, we're not gonna do that one. Never mind, we're taking that off the list. And so it's important to pay attention to those things. I talked about mixed supplements earlier that I'm not a big fan of, but even single agent supplements. Sometimes when you look at the ingredient list, you will see some sort of filler or binder or something like that. And sometimes patients can have an allergy or intolerance documented to one of those things as well. And so I think it's education to the patient, some responsibility of the provider for sure, but they're gonna be the one that ultimately goes out and purchases whatever it is they're gonna purchase. So giving them that education and knowledge up front so they can make an informed decision. Are there other populations or things, Colleen, that you look for when you are giving supplement advice to patients or to providers, other health conditions that I think are on your radar? That might be groups that maybe I'm just not encountering as often in the world of pain medicine.

Yeah, probably are chronic kidney patients, um, just from a metabolism standpoint, um, you know, pre-dialysis, post-dialysis, totally different needs, totally different kidney function. So it's probably one that I might defer to a renal dietitian if I don't feel comfortable. All right, so my primary care colleagues are cornered all the time into answering pretty complex, specific nutrition questions. And so I wanted you to help guide them and how you would answer or they could answer a patient who maybe says, Hey, is there anything natural that I can take for my pain? What would be sort of your quick tips, takeaways for how a clinician can answer that?

So I guess I would ask the patient to define what does natural mean to you? Because what it means to me, what it means to them, might be two very different things. And again, we're assuming here that they've done some sort of 24-hour dietary recall or food frequency questionnaire, and we know that their diet actually looks quite good. So then from there, what does natural mean to them? Is it they want to take some sort of turmeric tea or start incorporating ginger into their cooking? Or is it that they're speaking about a supplement? And then from there, I want to understand why they are asking me about this? What's their goal? What type of pain or condition is it that they're suffering from? And then can we kind of tailor what we're advising them more specifically to what they're seeking? So it I'm answering your question, but I'm not at the same time, because I would say as a provider, I need more information from that question.

It's a brilliant answer because that's how usually how I train all of my colleagues is like you need to answer their question with another question because, like you said, your answer might be different for every patient. So I actually love that answer, Chelsea. It's brilliant and quite appropriate because it's a hard thing to answer. Well, I'm so glad I got to pick your brain on this because it's complicated, right? So if you guys feel lost, don't feel alone. Hopefully, I was able to answer all of your questions that you guys had about supplements. I've talked about supplements previously on the podcast. I'll link down a couple of those episodes if you wanted to dig deeper into supplement regulation and safety. We've talked about that and especially with supplements regarding sports medicine. So all of those will be linked down for you in the show notes. Chelsea, thank you so much for the gift of your time. This was incredible. We've connected online, but if other people want to find you, where can they connect with you?

Best pace to find me is going to be on LinkedIn. Frankly, right now, with everything I have going on in life. That's the only social media platform that I keep up with and monitor. Be sure if you look for me that you spell my name right, Chelsea C H E L S E Y and Hoffman with two F's and two N's. Otherwise, you will not find me.

But I will make your life easier. I will link down to her in the show notes. Definitely get connected with her on LinkedIn. And you know me, I'm at Exam Room Nutrition on LinkedIn as well. Chelsea, thank you so much for the gift of your time.

Thank you so much for having me. It was a pleasure.