Accurate Education – Diet & Pain: An Overview

Diet & Pain: An Overview

For many, the role of diet – what and how we eat – is a hugely underestimated variable determining the extent of chronic pain one experiences. The diet one maintains affects not only one’s sensitivity to pain, but also the intensity and the development of the severity of pain. Despite the enormous impact diet has on chronic pain, dietary intervention is extremely underutilized as a means of treating chronic pain and improving quality of life.


The reason for this is largely based on the under-appreciation of the dietary role in chronic pain and the reluctance people have to changing their usual diet. Interestingly, it has also been shown that chronic pain contributes to an impaired sensation of satiation, or feeling full, leading to overeating. Chronic pain also appears to drive higher levels of carbohydrate and fatty food intake.


For those motivated to reduce their chronic pain and enhance their sense of well-being, however, changing one’s diet can be extremely helpful. The basis of dietary effects on pain are primarily based on the role of food intake on the microbiome (the bacteria in the intestinal tract) and on inflammation, both systemic and within the nervous system.The key to reducing pain through dietary management is to emphasize foods that enthance diversity in the microbiome and avoid foods that contribute to systemic inflammation.


And, while supplements play a role in restoring dietary health, they remain supplements, not substitutes, to a healthy diet.



See also:

Diet & Diets

Antioxidants and Oxidative Stress

NRF2 Activators

Nutrition: Amino Acids

Nutrition: Carbohydrates


Wellness Diets (coming soon):

Mediterranean Diet

Paleo Diet

Okinowan Diet

Elimination Diets


Diet Supplements:


NRF2 Activators

Mitochondrial Dysfunction




Key to Links:

Grey text – handout

Red text – another page on this website

Blue text – Journal publication


“The path to a healthier diet need not be as difficult to navigate as it may appear”

 – eeMD

Diet & Pain: an Overview

When should someone with chronic pain consider looking at their diet as a means of reducing their pain?

The answer is almost always. Given that Americans generally follow a less-than-ideal diet, there is always room for improvement and in many cases improvements can contribute to reduced pain. However, a more specific answer is when one’s pain or other symptoms are likely to be food-oriented or when one’s symptoms are poorly controlled and not responding to standard care. While the assessment of diet should not be delayed until reaching the point of desperation, this is often the case. But better late than never.


 For the most part, the discussion of diet and pain is a look at the forest, not the trees. While in certain cases of food allergies, food sensitivities and other food intolerances where even small amounts of specific foods can trigger pain and disease, the role of diet is otherwise a look at the big picture. The complete elimination of all “unhealthy” foods is not the goal in planning for a diet to reduce pain. In fact, most “unhealthy” foods become so mainly when they are eaten in excess.


How Pain and Diet are Related

Pain interfaces with diet in a number of ways that often overlap:

  1. Nutritional Deficiencies and Insufficiencies
  2. Inflammation and Oxidation
  3. Food Intolerances: Allergies and Sensitivities
  4. Intestinal Wall Integrity
  5. Gut Microorganisms (Microbiome)
  6. Impact on Prevention and Control of Painful Medical Conditions
  7. Pain appears to trigger excessive and/or emotional eating, including pleasure-eating


1.Nutritional Deficiencies and Insufficiencies

Nutritional deficiencies and insufficiencies are more common than one might expect. Frank deficiencies are less likely but insufficiencies, or levels that are suboptimal but not actually deficient resulting in classic deficiency syndromes, are not uncommon and often lead to pain and/or functional impairment.


Common nutritional deficiencies in America include Vitamin D and magnesium while common insufficiencies include zinc, certain B Vitamins and Vitamin C, certain amino acids, omega-3’s, fiber and antioxidants. Antioxidants are important in combating oxidative stress, the build-up of systemic free radicals, destructive byproducts of digestion and energy production that play an important role in the development of degenerative diseases, cancer and pain sensitivity. B vitamins are involved in a multitude of metabolic process that impact pain and deficiencies of Vitamins B1 and B12 lead to painful peripheral neuropathy. Vitamin C is a powerful antioxidant that is often insufficient in smokers and obesity and likely contributes to arthritis pain. Vitamin D, important for maintaining bone density, is also an anti-inflammatory and a significant player in pain.


Magnesium replacement has significant benefit for medical conditions that include muscle spasm and muscle pain, chronic headaches and fibromyalgia. Of particular significance to health and pain is an insufficient intake of the antioxidants found in fruits and vegetables. Omega-3’s and antioxidants impact health in many ways but insufficencies are major players in oxidative stress, inflammation and nerve pain.


In addition to fiber’s role in maintaining bowel function, fiber plays an important part in maintaining a healthy microorganism balance in the gut (microbiome – see below), where imbalances contribute to a number of painful conditions. Furthermore, the amount of fiber in one’s diet has been shown to be inversely proportional to the amount of pain associated with knee osteoarthritis. In other words, for those with knee arthritis, the more fiber in the diet, the less pain is likely to be associated with the knee arthritis.

See: Magnesium

See: Nutrition and Oxidative Stress


2. Diet and Inflammation

The “Standard American Diet (SAD)” is characterized by low intake of fruits, vegetables and fiber along with a high intake of processed grains, carbohydrates , sugars and poor quality fats and oils. In addition, it includes a multitude of additives including artificial sweeteners and preservatives. This SAD, especially with the high level of saturated animal fats, is associated with increased levels of inflammatory cytokines, chemicals that contribute to oxidative stress, pain sensitivity and systemic inflammation, including not just the joints in the extremities and spine but also the organs including the heart, blood vessels and liver.


Cytokines are small proteins released by cells that have a specific effect on the interactions and communications between cells. Cytokine is a general name; other names include lymphokine (cytokines made by lymphocyte immune cells), monokine (cytokines made by monocytes immune cells), adipokine (cytokines made by fat cells), and interleukin (cytokines made by one leukocyte immune cells and acting on other leukocyte immune cells).


Cytokines can be both pro- inflammatory cytokines or anti-inflammatory. Evidence shows that certain cytokines are involved in not only the initiation but also the persistence of pathologic pain by directly activating nerves that sense pain (nociceptive sensory neurons). Certain inflammatory cytokines are also involved in nerve-injury and inflammation-induced central sensitization, and are related to the development of chronic pain hypersensitivity (hyperalgesia & allodynia).

See Pain Definitions & Central Sensitization



How to effectively measure the degree of systemic inflammation of an individual has been elusive to medical science for decades. Many biomarkers have been identified that appear to be associated with systemic inflammation and often serve as measures of comparism between study groups and study outcomes. An inflammatory biomarker commonly measured in general medical practice is C-Reactive Protein (CRP).  It is commonly elevated in obesity and has also been correlated with osteoarthritis and low back pain. While clinically useful, CRP levels are limited in the amount of information they provide or predict. Another clinical biomarker of systemic inflammation is Interleukin-6, one of the Interleukin family of proteins associated with inflammation. Further information regarding the clinical use of measuring inflammatory biomarkers is forthcoming on this web site.


Obesity-Related Pain

Secondary consequences of the SAD is a predisposition to obesity, glucose intolerance and diabetes. Obesity is characterized by an abundance of fat cells that manufacture large amounts of inflammatory proteins leading to systemic inflammation. Studies show that obesity is an independent predictor of migraine headaches and of severe arthritis progressing to joint replacements of the knees and hips. Obesity is also associated with higher levels of neuropathic pain. Glucose intolerance and diabetes are associated with damages to nerves that leads to painful neuropathy.


Adipose tissue (or fat cells (adipocytes) – are now understood to be complex and highly dynamic, with endocrine, metabolic, and immune regulatory activity. Fat cells releases an abundanc of bioactive peptides or proteins, immune molecules, and inflammatory mediators named “adipokines” (only produced by the adipose tissue) or “adipocytokines” (primary but not exclusively produced by adipocytes). However, the term “adipokine” is used throughout here to refer to all these mediators, including Interleukins (IL-1, IL-6, IL-8), TNF (Tissue Necrosis Factor), adinopectin, leptin and resistin. A growing number of studies indicate that adipokines are significant contributors to the development of arthritis.


It should also be pointed out that systemic inflammation, obesity and pain are also inter-related with stress. depression, insomnia, sleep apnea, fatigue and physical deconditioning. These conditions interact on levels that sustain and enhance each other and contribute to overall impaired health, physical and emotional.


Anti-Inflammatory Diets for Pain Management

There are always many opinions as to what constitutes the healthiest diet and what people should eat. There are a number of proposed diets that are considered to be anti-inflammatory including the Mediterranean diet, the Paleo diet and the Okinawan diet, three currently popular versions. The Paleo diet appears to be a front runner currently but how one defines a Paleo diet is open to a wide range of interpretation and the reader is referred to other sites for more information at this time. The Mediterranean diet is also highly recommended as an anti-inflammatory diet to reduce chronic pain and also to reduce oxidative stress and the risk for atherosclerosis, heard disease and risk for stroke (see handouts below).


What is less controversial is what one should not eat: low fiber, calorie-dense, high fat, highly-processed foods. It has been well established that a diet rich in these products contributes to oxidative stress, obesity, cardiovascular disease and possibly some cancers as well as other diseases. For more information, please see the following handouts:

1.Wellness (Anti-inflammatory) Diet: Overview

2.Wellness Diet: Menu Examples


For more information regarding the rating of the inflammatory nature of individual foods, see resources below:

1. Anti-Inflammatory Food Ratings – A resource

2. Anti-Inflammatory Food – About Formula for Rating Foods and Link to Phone Apps



3. Food Intolerances Contributing to Pain: Allergies and Sensitivities

Specific foods can play a significant role in the health of certain individuals, leading to a wide range of mild to severely incapacitating symptoms, including gastrointestinal symptoms, neurological symptoms, fatigue and, importantly, pain. These symptoms may be the consequence of impaired digestion of a particular food, an allergic or antibody response to a food or simply a nonspecific intolerance due to inability to metabolize or other unknown mechanisms.


Intolerance to food can be the result of a reaction to either IgE or IgG antibodies. IgE antibody reactions result in typical, immediate-onset allergic reactions characterized by hives and/or life-threatening anaphylaxis. IgG antibody reactions (technically not allergic reactions) are more subtle and avoid obvious recognition in many cases. Food allergies and sensitivities can be tested for by measuring IgE and/or IgG antibody levels for various foods commonly associated with sensitivities. However, IgG testing is not very specific in identifying food sensitivities and may lead to incorrect conclusions. An alternative approach for identifying both food allergies and food sensitivities is use of the Elimination Diet (see below).


Food intolerance is related to the inability to digest or metabolize a nutrient. Food intolerance is not uncommon and includes lactose intolerance (due to insufficient lactase enzyme), histamine and tyramine (related to genetics or metabolic overload) intolerance. For those with symptoms of Irritable Bowel Syndrome (IBS), intolerance to FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) is common FODMAPs are commonly found in a wide variety of vegetables, fruits, beans, dairy products and teas. To identify specific FODMAP intolerances requires testing with an Elimination Diet (see below). Food intolerance symptoms are usually limited to g.i. complaints such as abdominal pain or cramps, bloating, nausea and diarrhea.


4. Intestinal Wall Integrity

When certain foods cannot be digested, often due to genetic factors, they can interact with the lining of the intestinal wall which can cause the release of a protein called zonulin, resulting in a loosening or disruption of the tight junction between the cells lining the intestine. This disruption contributes to greater permeability of the gut, called “Leaky Gut,” that allows foreign elements including undigested food, microorganisms and toxins in the gut to cross the intestinal wall barrier into the blood and systemic system. These foreign elements in turn can trigger the release of cytokines, proteins that stimulate inflammation and contribute to pain sensitization and/or trigger an immune response with the formation of antibodies. These antibodies then often interact with various tissues in the body, including joints, muscles and other organs causing inflammation, tissue destruction and other responses leading to illness and pain.


The hallmark of this type of reaction is Celiac Disease or Sprue, a genetically influenced condition in which sensitive individuals cannot digest gluten, a protein found in many grains, especially wheat, rye and barley. Celiac disease is characterized by many systemic symptoms including fatigue, arthritis and peripheral neuropathy amongst many others. Blood tests are available and fairly reliable for diagnosing Celiac Disease but other similar conditions lack specific tests. To identify other foods that might be responsible for such food sensitivities, the use of an Elimination Diet (see below) can be helpful.


Leaky Gut has been implicated in many medical conditions ranging from chronic migraine headaches to depression. Leaky Gut can be initiated by many triggers including the use of NSAIDs (non-steroid anti-inflammatory drugs including ibuprofen and naproxen) as well as by disruptions of the bacterial balance in the gut, the microbiome (See below).

See Leaky Gut


5. The Gut Microorganisms (Microbiome) and Pain

The TAD is associated with shifts and loss of diversity in the species of gut bacteria and other microorganisms. The bacterial balance of the microbiome affects pain through toxin production and candida (yeast) overgrowth. While our understanding of the role of gut bacteria in systemic health is still in it’s infancy, it has been recognized that these microbiome changes contribute to such diverse conditions as diabetes, depression, headaches, arthritis and other painful conditions. Men with chronic prostatitis and chronic pelvic pain have been found to have reduced diversity of the gut microbiome.


Studies indicate that the diversity of the microbiome is quickly subject to change, with a change in diet resulting in significant shifts in the microbiome in as little as 24 hours. It does not take long to improve the microbiome when an anti-inflammatory diet is engaged.


In addition to the gut microbiome contributing to pain, there is early evidence that the chronic use of morphine induces changes in the microbiome that contribute to loss of gut integrity and subsequent systemic inflammation. While this research is in its infancy, it does suggest there may be a role for modulating the microbiome as a means of pain management.


Diets to Support a Healthy, Diverse Microbiome

The best approach to maintaining an optimal microbiome – although the specifics concerning “optimal” remain ill-defined – is to maintain a high fiber diet, consuming 30 grams of fiber/day. The Paleo Diet has also been proposed to be supportive of a healthy gut microbiome. The use of prebiotics and probiotics is gaining popularity but it is too early to make specific recommendations as to choices of species and doses. For more information regarding probiotics, see:

1.A Gastroenterologist’s Guide to Probiotics – 2012

2.Probiotic Candian Clincial Guide to Probiotics


6. Dietary Impact on Prevention and Control of Painful Medical Conditions

While diet plays a large role in the development of diabetes and obesity, two conditions that are major contributors to chronic pain, diet also plays a large role in reducing the pain associated with these conditions. Diet is often a very effective tool for reducing or preventing chronic headaches. The pain and inflammation associated with chronic arthritis can often be significantly reduced with dietary changes, especially when accompanied by weight loss.


Other conditions in which modification of diet can have significant benefit in reducing pain include fibromyalgia, interstitial cystitis, endometriosis, irritable bowel syndrome (IBS) and inflammatory bowel conditions including Crohn’s disease and ulcerative colitis.


For condition-specific dietary approaches including the use of nutritional supplements, see:

  1. Arthritis
  2. Fibromyalgia
  3. Headaches
  4. Interstitial Cystitis


7. Pain change appetite, satiety and palatability of food

Chronic pain, especially in association with obesity has also been identified as triggering excessive eating through multiple mechanisms. Pain is linked to changes in satiety, in that it takes more food to feel full which contributes to overeating. Furthermore, pain appears to reduce how tasteful food can be. In contrast, hedonic hunger (appetite triggered by the seeking of pleasure from eating) is associated with chronic pain as well as emotional or binge-eating. A third variable, low mood or depression may also contribute to chronic pain and obesity and impact eating habits.


Identifying the Diets and Foods that Affect Pain


Unfortunately, it is seldom obvious what, or even if, a food sensitivity or intolerance is a significant contributor to a patient’s chronic pain, fatigue or other symptoms. How does one investigate a person’s symptoms or pain as to whether a particular food or diet is a significant contributor? The first step is to begin moving towards an anti-inflammatory diet such as the Mediterranean, Paleo or Okinawan diets by eliminating or reducing foods known to contribute to inflammation and oxidative stress. If this move is inadequate to reduce symptoms to an acceptable level a more aggressive approach is indicated. Medical conditions that are most likely to be improved by dietary intervention include arthritis (osteoarthritis or rheumatoid arthritis), chronic headaches, fibromyalgia, chronic fatigue and those with symptoms related to the gut, including irritable bowel syndrome and inflammatory bowel conditions including Crohns and ulcerative colitis.


In order to identify specific foods that may be contributing to pain or other multiple, unexplained symptoms, the most effective approach is to engage an Elimination Diet. An Elimination Diet removes all suspicious foods from the patient’s diet for a period of 3-4 weeks at which point the patient reassesses their level of symptom control. The foods on the “most suspicious” list includes lactose and dairy products, gluten and the artificial low-calorie sweetener, aspartame. An Elimination Diet requires careful planning, guidance and execution to be successful.

For more information, see Elimination Diets


Making the Changes

Small Steps

For those reluctant to commit to making “big” changes in how they eat, there are some simple steps one can start with that are effexive:


  1. Eat more slowly

  2. Reduce portion size

  3. Substitute healthier favorite food choices


1. Eating More Slowly

Studies show that finishing a meal in less than 15 minutes is associated with higher caloric intake, higher cholesterol levels and greater systemic inflammation. Spending more time chewing improves digestion and slower eating leads to arresting the appetite with eating less food.


In recent studies eating rate was significantly and positively associated with the development of metabolic syndrome, a collection of conditions associated with increased risk of heart disease and stroke (High blood pressure, Elevated sugar, Central obesity, Low HDL (good cholesterol) and High triglycerides ). This trend may be of greater significance in men than women, at least in the Japanese population. Of metabolic syndrome components, abdominal obesity showed the strongest association with eating rate. The association of slow eating with lower odds of high blood pressure (men and women) and high blood sugar (men) and that of fast eating with higher odds of lipid (cholesterol) abnormality (men) is statistically significant.


A study indicated that self-reported faster eating is positively associated with visceral fat accumulation, independently of subcutaneous fat accumulation. Visceral fat, the fat surrounding organs within the abdomen, is known to contribute more to development of systemic inflammation than fat distributed over the rest of the body in the subcutaneous layers.


Another finding associated with fast eating is that of increased likelihood of elevated blood levels of ALT (alanine aminotransferase), a liver enzyme that is a biomarker for liver damage and can be seen with fatty liver.


2. Reducing Portion Size

Serve yourself smaller than usual servings – and commit yourself to it. Especially if combined with eating more slowly, this practice will retrain appetite and restore healthier levels of food intake.


3. Substituting Healthier Favorite Food Choices

Ultimately, the successful reduction in pain will require significant changes in foods most people in America eat. By starting slowly with choosing healthier favorite foods, it facilitates a start in the right direction. Every journey begins with a single step – when this step is more likely to be successful, it allows for a build-up of the momentum of change.




Anti-Inflammatory Diet – Resources

  1. Anti-Inflammatory Food Ratings – A resource
  2. Anti-Inflammatory Food – About Formula for Rating Foods and Link to Phone Apps
  3. An extensive bibliography of research on the effects of individual nutrients on inflammation


Anti-Inflammatory Diet – References

  1. Cytokines, Inflammation and Pain – 2007



Western Diet – Overview

  1.  Total Western Diet (TWD) alters mechanical and thermal sensitivity and prolongs hypersensitivity following Complete Freund’s Adjuvant in mice – 2016


Diet – Fibromyalgia

  1. A low fermentable oligo-di-mono-saccharides and polyols (FODMAP) diet is a balanced therapy for fibromyalgia with nutritional and symptomatic benefits – PubMed – NCBI


Diet – Water

  1. Water, Hydration and Health – 2010
  2. healthy_hydration_toolkit_march_2015


Fast Eating

  1. Self-reported faster eating associated with higher ALT activity in middle-aged, apparently healthy Japanese women. – PubMed – NCBI
  2. Self-awareness of fast eating and its impact on diagnostic components of metabolic syndrome among middle-aged Japanese males and females. – PubMed – NCBI
  3. Self-reported faster eating is positively associated with accumulation of visceral fat in middle-aged apparently healthy Japanese men. – PubMed – NCBI
  4. Association Between Eating Speed and Metabolic Syndrome in a Three-Year Population-Based Cohort Study – 2015
  5. Self-reported eating rate and metabolic syndrome in Japanese people – cross-sectional study -2014


Eating – Appetite, Satiation and Pain

  1. Decreased food pleasure and disrupted satiety signals in chronic low back pain. – PubMed – NCBI


The Microbiome – Overview



The Microbiome – Arthritis and Rheumatic Diseases

  1. Microbiome in Inflammatory Arthritis and Human Rheumatic Diseases – 2017
  2. A Possible Role of Intestinal Microbiota in the Pathogenesis of Ankylosing Spondylitis – 2016
  3. Hypothesis – Time for a gut check – HLA B27 predisposes to ankylosing spondylitis by altering the microbiome


The Microbiome – Inflammatory Bowel Disease

  1. The microbiota in inflammatory bowel disease – current and therapeutic insights – 2017
  2. Diet in the Pathogenesis and Treatment of Inflammatory Bowel Diseases – 2015


The Microbiome – Obesity

  1. Innate sensors of pathogen and stress: linking inflammation to obesity. – PubMed – NCBI
  2. Microbiota, inflammation and obesity. – PubMed – NCBI
  3. Obesity-Driven Gut Microbiota Inflammatory Pathways to Metabolic Syndrome – 2015
  4. Gut microbiota as a key player in triggering obesity, systemic inflammation and insulin resistance. 2014 – PubMed – NCBI


The Microbiome – Opioids

  1. Chronic Opioid Use Is Associated With Altered Gut Microbiota and Predicts Readmissions in Patients With Cirrhosis – 2017
  2. Opioid-induced gut microbial disruption and bile dysregulation leads to gut barrier compromise and sustained systemic inflammation – 2016


The Microbiome – Probiotics

  1. A Gastroenterologist’s Guide to Probiotics – 2012
  2. Probiotic Candian Clincial Guide to Probiotics


The Microbiome – Pain

  1. The gut microbiota as a key regulator of visceral pain – 2017


The Microbiome – Surgery

  1. Gut microbiome, surgical complications and probiotics – 2017



Food Sensitivities – Overviews


Food Sensitivities – Gluten

  1. Non-coeliac-gluten-sensitivity-e-A-new-disease-with-gluten-intolerance-2015



  1. Kaempferol, a dietary flavonoid, ameliorates acute inflammatory and nociceptive symptoms in gastritis, pancreatitis, and abdominal pain. – PubMed – NCBI
  2. Advanced Glycation End Products in Foods and a Practical Guide to Their Reduction in the Diet – 2010


Obesity – Pain

  1. Obesity-related adipokines predict patient-reported shoulder pain – 2013
  2. Adipokine Contribution to the Pathogenesis of Osteoarthritis – 2017
  3. Relationship between Neuropathic Pain and Obesity – 2016
  4. “The more pain I have, the more I want to eat” – obesity in the context of chronic pain – 2012



Emphasis on Education


Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.


For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.


Should you wish more information regarding any of the subjects listed – or not listed –  here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.


For more information, please contact Accurate Clinic.


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