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Examining Risk for Persistent Pain among Adults with Overweight Status
Review Article Examining Risk for Persistent Pain among Adults with Overweight Status Teresa Bigand, RN, MSN, CMSRN, CNL, Marian Wilson, PhD, MPH, RN-BC, Ruth Bindler, PhD, MSN, and Kenn Daratha, PhD, MBA ---
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From the Washington State University, Spokane, Washington. Address correspondence to Teresa Bigand, RN, MSN, CMSRN, CNL, Washington State University, 412 East Spokane Falls Boulevard, Spokane, WA 99202. E-mail: teresa.bigand@ wsu.edu Received July 27, 2017; Revised January 10, 2018; Accepted February 17, 2018. 1524-9042/$36.00 Ó 2018 by the American Society for Pain Management Nursing https://doi.org/10.1016/ j.pmn.2018.02.066
ABSTRACT:
Aims of Investigation: Obesity and persistent pain are public health concerns with associated high costs. Evidence supports an increased risk for reports of persistent pain among adults who are above the recommended body mass index level. However, data have not been clearly synthesized to report the risk for the two co-occurring conditions. Even less is known about how overweight status that does not reach the level of obesity is related to pain. Thus, the aim driving this review was to calculate the risk and odds ratios of chronic pain among adults with an overweight body mass index. Methods: A literature review was completed using CINAHL and PubMed databases. Key words were entered using combinations of several MeSH headers. Results: Risk and odds ratios were calculated to determine overweight status among adults with chronic pain. Risk and odds ratios were calculated from nine studies. Overweight adults were between 14% and 71% more likely to report chronic pain than normal-weight adults. Implications for Practice: Pain management nurses should educate adults about the importance of weight management to reduce risk for persistent pain. Nurses need to be informed about current national physical activity and diet recommendations to ensure proper health information is relayed to patients. Conclusions: There is an elevated risk for persistent pain among adults who are overweight compared with those who are recommended weight status. Future longitudinal research focused on causality can help determine which condition contributes to the other. Weight management may be implied for clinical risk reduction of pain conditions among adults who are above recommended body mass index levels. Ó 2018 by the American Society for Pain Management Nursing The prevalence of overweight adults has been significantly increasing worldwide. Today, more than 33% of adults in the United States are classified as obese (OB), or body mass index (BMI) greater than 30 (Ogden, 2012). Greater than 69% of the US population is overweight, defined as BMI greater than 25 (Ogden, Pain Management Nursing, Vol 19, No 5 (October), 2018: pp 549-556
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Carroll, Kit, & Flegal, 2012). This is concerning because being overweight is linked to costly chronic health conditions with high morbidity and mortality rates such as diabetes, heart disease, stroke, and some cancers (Centers for Disease Control and Prevention [CDC], 2017). Data indicate that adults with overweight BMI are more likely to report chronic pain than those with normal BMI (Fowler-Brown, Wee, Marcantonio, Ngo, & Leveille, 2013; McCarthy, Bigal, Katz, Derby, & Lipton, 2009; Stone & Broderick, 2012; Wright et al., 2010). Higher BMI is also correlated with greater pain interference, depressive symptoms, and disability among adults with chronic pain (Allen, Da Grande, Abernathy, & Currow, 2016; Marcus, 2004). Chronic or persistent pain, defined as pain that is present most days in the past 3 or more months, is estimated to affect 100 million adults in the United States at an annual cost of roughly $635 billion (American Academy of Pain Medicine, 2011). Current costs related to health care and loss of workplace productivity related to overweight status are estimated at $214.3 billion per year (Robert Wood Johnson Foundation, 2016). Both conditions are costly, and solutions to concurrently address the epidemics are critical public health and nursing concerns.
BACKGROUND The mechanisms by which overweight BMI is thought to contribute to chronic pain are multifactorial. One non-modifiable factor is genetics. Data indicate that twin pairs with obesity are more likely to have chronic pain than twin pairs with normal weight (Wright et al., 2010). Additionally, adult children were found to be significantly more likely to suffer chronic pain if one or both parents had chronic pain, as opposed to adult children whose parents were both pain free (Lier, Mork, Holtermann, & Nielson, 2016). In contrast, learned behaviors may create unhealthy habits, such as sedentary lifestyle and overconsumption of fatty foods, which may increase risk of obesity and chronic pain (Bonakdar, 2013). Furthermore, the accessibility of ready-made, tasty, unhealthy foods may facilitate overindulgence, which can result in weight gain and may create bodily aches from the additional weight (Narouze & Souzdalnitski, 2015). Overeating may also be a behavior common to adults with chronic pain. A study by Janke and Kozak (2012) found that a sample of adults with overweight status and obesity reported overeating to soothe chronic pain, which led to guilt and triggered further unhealthy eating habits. Meleger, Froude, and Walker (2014) conducted an observational study on diet among a small sample of adults with chronic pain and found
that participants overconsumed sodium, added sugars, fats, caffeine, and calories and were deficient in vitamins with respect to US national nutrition guidelines. A review by Okifuji and Hare (2015) summarizes the strong association between depressive symptoms, poor sleep, chronic pain, and overeating and cites studies that indicate that surgical and natural weight loss may improve pain outcomes in overweight adults. Another contributing factor relating overweight status to chronic pain involves the load on joints from excessive weight, which causes increased pressure and painful tissue damage (Zdziarski, Wasser, & Vincent, 2015). This mechanism only partially explains the relationship, however, as overweight status has been linked to increased risk of pain in non–weight-bearing joints such as the hands (Bonakdar, 2013; Narouze & Souzdalnitski, 2015) or the head in migraine headaches (Wright et al., 2010). A prominently cited cause of obesity-related pain is inflammatory and metabolic processes (Bonakdar, 2013; Narouze & Souzdalnitski, 2015; Okifuji & Hare, 2015; Zdziarski et al. 2015). This state increases pain sensitivity and, when it occurs long term, may lead to chronic fatigue syndrome, promoting a sedentary lifestyle and reducing the likelihood of weight loss. Although evidence clearly indicates that overweight status is associated with chronic pain conditions, and multiple theories exist as to why this might occur, the worldwide prevalence of chronic pain among adults with overweight BMI compared with those with a normal BMI is unclear, especially when overweight status is distinguished from obesity. The risk for reports of persistent pain among adults with overweight BMI that is not specific to obesity therefore needs to be further explored to illuminate avenues for reducing risks associated with both health conditions. The primary aim of this literature review, therefore, was to uncover the current risk for reports of pain based on recent global data on adults with and without an overweight BMI.
METHODS A review of the literature was performed to determine global prevalence and risk of chronic or persistent pain among adults based on BMI. CINAHL and PubMed are two widely used and comprehensive medical databases and, thus, were chosen for this review. A search strategy was developed using combinations with the following MeSH terms: chronic, persistent, pain, associat*, overweight, obes*, and prevalen*. Asterisks were used to increase the search strategy; for example, ‘‘obes*’’ as a search stem returns articles with key words of both obesity and obese. Figure 1 is a
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Pain among Overweight Adults
PubMed: 977
CINAHL: 378
Duplicates Removed
Abstracts Screened: 65
Studies within Criteria: 9
FIGURE 1. - Flowchart indicating number of studies returned and screened.
flowchart indicating number of studies returned and screened. Studies were included if written between the years 2000 and 2016 in the English language, if data on presence of chronic pain among a population of adult males and females were available, and if numbers of adults with and without pain and corresponding BMI values below and above 25 were presented. This review limited analysis to overweight adults as a preliminary investigation, as this definition encompasses a greater percentage of the population than strictly obese; thus, articles that provided information on adults with obesity but not overweight were excluded. A total of nine research articles met criteria for review. Table 1 summarizes how risk and odds ratios were calculated.
RESULTS A total of nine articles were used to calculate risk and odds ratios of chronic pain diagnoses or reports among overweight adults as compared with adults with
normal weight. Sample sizes ranged from 736 to 24,450 participants. Studies were conducted in North and South America, Western and Eastern Europe, and Australia. All nine studies demonstrated an odds ratio greater than 1.0, though none was greater than 2.0, suggesting a moderately higher risk for reports of chronic pain among adults with BMI greater than 25 as compared with those with a normal-weight BMI. Calculated relative risk ratio varied widely among the samples and revealed that adults with overweight status had between 14% and 71% greater risk of reporting persistent pain than adults with normalweight status, with the average being 34%. c2 values were calculated and reached significance at the 0.05 level, except for one study where c2 ¼ 0.08. Table 2 provides more details including the definition of chronic pain that each respective study used.
DISCUSSION Populations with overweight and chronic pain reports are increasingly more prevalent and both conditions present multiple health risks. Data provided here support the findings of a relationship between chronic pain and an elevated BMI. Specifically, the risk for reports of chronic pain is greater for a person with a BMI greater than 25 than it is for a person with a BMI less than 25. Many studies also report that BMI is related to persistent pain in a dose-dependent way; in other words, risk for a chronic pain diagnosis increased as BMI increased above normal (Stone & Broderick, 2012; Wright et al., 2010). This is a clinically significant finding, although this was not a primary aim of the current literature review. One of the studies from this analysis had a risk and odds ratio that did not meet the 0.05 significance level for the c2 test, which could have been due to a relatively small sample size (826) focused on adults
TABLE 1. Risk for Pain Among Overweight Compared to Recommended Weight Adults Risk
Risk Ratio
Odds
Odds Ratio
Overweight adults þ pain/total overweight adults ¼ risk for pain among overweight adults Normal-weight adults þ pain/total adults with pain ¼ risk for pain among normal-weight adults
Risk value for pain among overweight adults/risk value for pain among normal-weight adults ¼ risk for pain among overweight adults
Overweight adults þ pain/ overweight adults without pain ¼ odds of pain among overweight adults Normal-weight adults with pain/normal-weight adults without pain ¼ odds of pain among normalweight adults
Odds value for pain among overweight adults/odds value for pain among normal-weight adults ¼ odds of pain among overweight adults
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TABLE 2. Calculated Risk and Odds Ratios for Reports of Pain Among Overweight Compared to Recommended Weight Adults
Study and Year Heuch et al., 2013
Fowler-Brown et al., 2013
McCarthy et al., 2009
Allen et al., 2016
Jakobsson, 2010 Vandenkerkhof et al., 2011 Lake et al., 2000
Ohayon and Stingl, 2012 Gouveia et al., 2016
Chronic Pain Definition National Health Questionnaire (presence of low back pain last 3 continuous months in previous year) Brief Pain Inventory and Joint Pain Questionnaire (pain in joints or all over on most days for past 3 mo or longer) Total Pain Index (moderate pain, >3/10, lasting greater than 3 mo) South Australian Health Omnibus Survey (pain lasting 3 of the past 6 mo) Survey (pain in last 3 mo or longer) Survey (widespread pain in last 3 mo per fibromyalgia definition) Questions from validated survey (pain in low back lasting $3 mo) Phone survey (pain lasting $3 mo) Self-report (presence of low back pain in past 90 þ days)
Prevalence of Overweight Status among Adults with Pain
Relative Risk
Odds Ratio
Total Sample Size
p Value (c2 Test)
Time 2: 4,349/ 6,848 ¼ 64%
1.14
1.196
24,450
<0.001
249/330 ¼ 75%
1.41
1.801
736
<0.001
273/424 ¼ 64%
1.21
1.483
819
<0.01
402/644 ¼ 63%
1.41
1.573
2,616
155/309 ¼ 50%
1.17
1.286
826
Time 2: 455/909 ¼ 50%
1.45
1.032
6,948
<0.001
409/1,021 ¼ 40%*
1.152
1.173
9,134
0.02
352/752 ¼ 47%
1.442
1.198
3,011
0.03
941/1,346 ¼ 70%
1.713
1.858
4,091
<0.001
<0.001
0.08
*These data indicate childhood and young adult body mass indexes for those who report low back pain at age 33.
18 years and older. In contrast, some studies suggest that age older than 55 years may present greater risk for comorbid pain and overweight conditions as compared with younger ages (Allen et al., 2016; Stone & Broderick, 2012). Other studies from this literature review with comparably small sample sizes were focused on the adult population aged 65 and older (Fowler-Brown et al., 2013; McCarthy et al., 2009), which could have contributed to the significant findings. Several considerations need to be made when interpreting the data calculated from this analysis. These include limited availability of longitudinal data, differences in measuring chronic
pain, lack of diverse geographical data, differences in BMI calculation, and BMI as healthy weight determinant. Limited Longitudinal Data Most of the studies selected in this review were crosssectional in nature, meaning that the variable of change over time is not considered. Thus, it is not clear whether chronic pain predisposes one to an overweight BMI or if the opposite is true. Two studies that fit criteria for this review did look at a group of adults over time with the question of cause or effect in terms of chronic low back pain and BMI. Heuch,
Pain among Overweight Adults
Heuch, Hagen, and Zwart (2013) followed a group of Norwegian adults for 18–10 years, and although they found no difference in BMI between adults with and adults without pain between time points 1 and 2, there was a significantly higher odds ratio for development of chronic low back pain at the 10-year follow-up for those with overweight BMI at time point 1 as compared with those who were normal weight. This lends some evidence to the notion that elevated BMI is a risk factor for future development of chronic low back pain. The second longitudinal study by Lake, Power, and Cole (2000) assessed data from the British birth cohort, in which all babies born between a few specific days in Great Britain were invited to join this life-long research effort. At ages 23 and 33, BMI and chronic low back pain were measured, and results revealed that women who had an overweight BMI at 23 had a significantly greater odds ratio of development of chronic low back pain at age 33 and gained an average of 1.1 kg (2.42 pounds) more than normal-weight females over the time frame. Men had similar risks, though calculated values did not achieve statistical significance. These data also suggest that higher BMI poses a risk for development of low back pain over time as opposed to the other way around, and though the sample with pain at time point 1 did gain more weight at time point 2 than those without pain, the number is clinically insignificant at only 2.42 pounds more than the normal-weight group. Regarding the impact of chronic pain on weight, a recent longitudinal study in England followed overweight adults with chronic pain who were attempting to lose weight, and after 1 year, the group with reports of severe pain lost significantly less weight (on average 11 pounds) than the groups who reported small to moderate levels of pain (Ryan et al., 2017). Thus, it appears that weight and pain self-management are barriers among overweight adults with chronic pain. Differing Chronic Pain Definitions The purpose of this study was to investigate risk for any type of chronic pain among overweight adults. However, many studies that met criteria for this review focused on one specific type of pain. Three studies, for example, focused on BMI among adults with persistent low back pain (Gouveia et al., 2016; Heuch et al., 2013; Lake et al., 2000). Another from this review limited pain measurements to chronic widespread pain, which defines fibromyalgia (Vandenkerkhof, Macdonald, Jones, Power, & Macfarlane, 2011). The remaining studies did not specify a pain diagnosis or location. Wright et al. (2010) differentiated pain types among participants and found that overweight adults
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had a greater risk for all pain conditions, but only abdominal pain, low back pain, fibromyalgia, chronic widespread pain, and migraines reached statistical significance. Thus, there is a need to perform longitudinal studies that report incidences of all types of chronic pain as relates to BMI to investigate whether populations with overweight have increased risk of development of all or certain types of chronic pain diagnoses. In addition, chronic pain was defined differently among the studies. Allen et al. (2016) operationalized chronic pain as pain occurring at least 3 of the past 6 months, whereas the rest of the studies defined it as pain lasting most days in the past 3 months (Fowler-Brown et al., 2013; Gouveia et al., 2016; Heuch et al., 2013; Jakobsson, 2010; Lake et al., 2000; McCarthy et al., 2009; Ohayon & Stingl, 2012; Vandenkerkhof et al., 2011). Limited Geographical Diversity of Study Samples Although this literature review was meant to explore the global risk and odds ratio for chronic pain diagnoses among overweight adults, no studies matching the search criteria were found that were published in countries in Asia, Africa, Middle East, Pacific Islands, or South America, thus limiting ability to generalize findings on a worldwide scale. Although the prevalence of overweight status and obesity is significantly lower in Japan than in Western countries, a recent longitudinal study was conducted among Japanese males that supported evidence that a dose-dependent relationship exists between overweight status and low back pain (Hashimoto et al., 2017). Prevalence studies among males and females are needed to examine the relationship between overweight status and chronic pain among diverse populations, especially in countries of low socioeconomic status (SES), as data is scarce regarding these conditions and treatment options in such areas. A meta-analysis suggests that overweight is a concern in countries with low SES (Dinsa, Goryakin, Fumagalli, & Suhrcke, 2012), and a cross-sectional study conducted among inhabitants of Iran confirms that people with obesity face increased odds of having chronic low back pain reports in this population (Noormohammadpour et al., 2016). However, it is unknown what current risks are for reports of persistent pain among adults with overweight status in countries outside of those mentioned in this report. BMI Measurement Body mass index was calculated through self-reported height and weight data in more than half of the studies included in this analysis (Allen et al., 2016; Jakobsson,
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2010; Lake et al., 2000; McCarthy et al., 2009) and was measured by professionals in the remaining studies (Fowler-Brown et al., 2013; Gouveia et al., 2016; Heuch et al., 2013; Vandenkerkhof et al., 2011). Self-report of height and weight may not be as accurate as professionally obtained values (Stommel & Osier, 2013). Studies are lacking to validate accuracy of self-report of height and weight among populations of adults with persistent pain and overweight status. In addition, the current literature review restricted the calculation of risk and odds ratios for presence of pain to overweight BMI, defined as 25 or greater, compared with adults with a BMI less than 25. Clinically, risk for adverse health outcomes is more commonly seen with an obese BMI of 30 or greater (CDC, 2017). Thus, a limitation of this review is the focus only on studies offering data on adults with overweight status as opposed to obesity. The clinical relevance of this review is the finding that compared with a norrmal-weight BMI, an overweight BMI was associated with greater risk for reports of persistent pain, highlighting the importance of weight management education of overweight and not only obese adults to reduce this risk. BMI as Healthy Weight Determinant There has been some critique of the use of BMI alone as a marker for disease. Researchers using the British birth cohort data analyzed differences between different anthropometric measures in correlating chronic low back pain, yet found BMI to continue to be a significant predictor, though total fat mass was a stronger predictor of pain (Heuch, Heuch, Hagen, & Zwart, 2015). In another study, chronic low back pain and association between BMI and body fat percentage were assessed in Japanese males, and although body fat percentage was found to be a better predictor of the relationship, BMI remained statistically significantly associated (Hashimoto et al., 2017). In contrast, a small study found that the use of BMI was a poor predictor of athletes versus non-athletes, as opposed to percentage fat mass, which was a highly sensitive predictor (Kruschitz et al., 2013). This lends question to the usefulness of BMI in determining healthy body composition and in screening for health conditions such as chronic pain. Future research should be conducted to derive the best measure of body weight to identify risk for persistent pain conditions. Implications for Practice Overweight status increases risk for reports of persistent pain in the global general population. Longitudinal studies indicate that past overweight
status is more important in predicting future pain than past pain is in influencing future overweight status. Implications for the pain management nurse include educating patients to achieve and maintain a normal body weight through proper diet and exercise, as this may help adults reduce risk for reports of persistent pain. Achieving and maintaining a recommended body weight will also reduce the risk for adults with persistent pain of developing obesity-related medical conditions such as diabetes and heart disease (CDC, 2017). According to the American Heart Association (2016), adults should be encouraged to engage in a minimum of 150 minutes of moderate-intensity aerobic exercise each week for cardiac health benefits. A meta-analysis of weight loss studies among adults with chronic low back pain revealed that swimming, yoga, and weight-training exercises were the most effective in safely facilitating weight loss and improvement in pain intensity and pain disability in this group (Wasser, Vasilopoulos, Zdziarski, & Vincent, 2017). Thus, nurses can educate overweight adults with pain to incorporate 150 minutes per week of one of these kinds of exercises into their daily routine for improved pain and weight health outcomes. Research suggests that exercise alone is not significantly effective in producing improved weight and pain health outcomes among overweight adults with persistent pain; rather, combining exercise and a proper diet is most beneficial (Kumar, Beavers, Devita, & Messier, 2017). National dietary standards were recently published and are important for nurses and patients alike to read and follow (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). One method of encouraging adults with pain to follow a balanced diet to facilitate weight loss as recommended by national standards may be through promoting the use of an electronic food diary which calculates total daily calories and macronutrient information based on the foods and servings input by the user. Evidence indicates that the use of mobile applications to track food intake and activity levels leads to greater weight loss than traditional methods alone (Spring, Duncan, & Janke, 2013). Several such free applications exist; a quick Google search with the terms ‘‘food diary apps’’ returns nearly 1.6 million results. Many nutrition applications offer a built-in macronutrient calculator to allow the user to indicate personal height, weight, and activity level, and based on these data, unique daily caloric and macronutrient needs for weight loss are calculated. However, the use of such applications has not been thoroughly tested among adults with persistent pain diagnoses. In the
Pain among Overweight Adults
light of the growing obesity and chronic pain epidemics, more education for the general adult population on weight self-management may be indicated to mitigate the prevalence and impact of persistent pain.
CONCLUSIONS The studies conducted among individuals aged 15 and older have indicated, both in cross-sectional and in large, longitudinal designs, that there is a relationship between chronic pain and overweight status. Longitudinal studies suggest that overweight status is more important in predicting later or
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recurrent chronic back pain as opposed to chronic back pain contributing to weight gain and overweight status over time. The relationship between weight status and pain is not well known other than for low back or osteoarthritis conditions (CDC, 2017). Few studies to date have investigated whether moderate weight gain that does not reach criteria for obesity can influence pain. Given the dearth of global studies that associate overweight status with persistent pain, it will be prudent to collect more high-quality, longitudinal data to further investigate this relationship, especially in countries where there are no well-documented data on this phenomenon.
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From the Washington State University, Spokane, Washington. Address correspondence to Teresa Bigand, RN, MSN, CMSRN, CNL, Washington State University, 412 East Spokane Falls Boulevard, Spokane, WA 99202. E-mail: teresa.bigand@ wsu.edu Received July 27, 2017; Revised January 10, 2018; Accepted February 17, 2018. 1524-9042/$36.00 Ó 2018 by the American Society for Pain Management Nursing https://doi.org/10.1016/ j.pmn.2018.02.066
ABSTRACT:
Aims of Investigation: Obesity and persistent pain are public health concerns with associated high costs. Evidence supports an increased risk for reports of persistent pain among adults who are above the recommended body mass index level. However, data have not been clearly synthesized to report the risk for the two co-occurring conditions. Even less is known about how overweight status that does not reach the level of obesity is related to pain. Thus, the aim driving this review was to calculate the risk and odds ratios of chronic pain among adults with an overweight body mass index. Methods: A literature review was completed using CINAHL and PubMed databases. Key words were entered using combinations of several MeSH headers. Results: Risk and odds ratios were calculated to determine overweight status among adults with chronic pain. Risk and odds ratios were calculated from nine studies. Overweight adults were between 14% and 71% more likely to report chronic pain than normal-weight adults. Implications for Practice: Pain management nurses should educate adults about the importance of weight management to reduce risk for persistent pain. Nurses need to be informed about current national physical activity and diet recommendations to ensure proper health information is relayed to patients. Conclusions: There is an elevated risk for persistent pain among adults who are overweight compared with those who are recommended weight status. Future longitudinal research focused on causality can help determine which condition contributes to the other. Weight management may be implied for clinical risk reduction of pain conditions among adults who are above recommended body mass index levels. Ó 2018 by the American Society for Pain Management Nursing The prevalence of overweight adults has been significantly increasing worldwide. Today, more than 33% of adults in the United States are classified as obese (OB), or body mass index (BMI) greater than 30 (Ogden, 2012). Greater than 69% of the US population is overweight, defined as BMI greater than 25 (Ogden, Pain Management Nursing, Vol 19, No 5 (October), 2018: pp 549-556
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Carroll, Kit, & Flegal, 2012). This is concerning because being overweight is linked to costly chronic health conditions with high morbidity and mortality rates such as diabetes, heart disease, stroke, and some cancers (Centers for Disease Control and Prevention [CDC], 2017). Data indicate that adults with overweight BMI are more likely to report chronic pain than those with normal BMI (Fowler-Brown, Wee, Marcantonio, Ngo, & Leveille, 2013; McCarthy, Bigal, Katz, Derby, & Lipton, 2009; Stone & Broderick, 2012; Wright et al., 2010). Higher BMI is also correlated with greater pain interference, depressive symptoms, and disability among adults with chronic pain (Allen, Da Grande, Abernathy, & Currow, 2016; Marcus, 2004). Chronic or persistent pain, defined as pain that is present most days in the past 3 or more months, is estimated to affect 100 million adults in the United States at an annual cost of roughly $635 billion (American Academy of Pain Medicine, 2011). Current costs related to health care and loss of workplace productivity related to overweight status are estimated at $214.3 billion per year (Robert Wood Johnson Foundation, 2016). Both conditions are costly, and solutions to concurrently address the epidemics are critical public health and nursing concerns.
BACKGROUND The mechanisms by which overweight BMI is thought to contribute to chronic pain are multifactorial. One non-modifiable factor is genetics. Data indicate that twin pairs with obesity are more likely to have chronic pain than twin pairs with normal weight (Wright et al., 2010). Additionally, adult children were found to be significantly more likely to suffer chronic pain if one or both parents had chronic pain, as opposed to adult children whose parents were both pain free (Lier, Mork, Holtermann, & Nielson, 2016). In contrast, learned behaviors may create unhealthy habits, such as sedentary lifestyle and overconsumption of fatty foods, which may increase risk of obesity and chronic pain (Bonakdar, 2013). Furthermore, the accessibility of ready-made, tasty, unhealthy foods may facilitate overindulgence, which can result in weight gain and may create bodily aches from the additional weight (Narouze & Souzdalnitski, 2015). Overeating may also be a behavior common to adults with chronic pain. A study by Janke and Kozak (2012) found that a sample of adults with overweight status and obesity reported overeating to soothe chronic pain, which led to guilt and triggered further unhealthy eating habits. Meleger, Froude, and Walker (2014) conducted an observational study on diet among a small sample of adults with chronic pain and found
that participants overconsumed sodium, added sugars, fats, caffeine, and calories and were deficient in vitamins with respect to US national nutrition guidelines. A review by Okifuji and Hare (2015) summarizes the strong association between depressive symptoms, poor sleep, chronic pain, and overeating and cites studies that indicate that surgical and natural weight loss may improve pain outcomes in overweight adults. Another contributing factor relating overweight status to chronic pain involves the load on joints from excessive weight, which causes increased pressure and painful tissue damage (Zdziarski, Wasser, & Vincent, 2015). This mechanism only partially explains the relationship, however, as overweight status has been linked to increased risk of pain in non–weight-bearing joints such as the hands (Bonakdar, 2013; Narouze & Souzdalnitski, 2015) or the head in migraine headaches (Wright et al., 2010). A prominently cited cause of obesity-related pain is inflammatory and metabolic processes (Bonakdar, 2013; Narouze & Souzdalnitski, 2015; Okifuji & Hare, 2015; Zdziarski et al. 2015). This state increases pain sensitivity and, when it occurs long term, may lead to chronic fatigue syndrome, promoting a sedentary lifestyle and reducing the likelihood of weight loss. Although evidence clearly indicates that overweight status is associated with chronic pain conditions, and multiple theories exist as to why this might occur, the worldwide prevalence of chronic pain among adults with overweight BMI compared with those with a normal BMI is unclear, especially when overweight status is distinguished from obesity. The risk for reports of persistent pain among adults with overweight BMI that is not specific to obesity therefore needs to be further explored to illuminate avenues for reducing risks associated with both health conditions. The primary aim of this literature review, therefore, was to uncover the current risk for reports of pain based on recent global data on adults with and without an overweight BMI.
METHODS A review of the literature was performed to determine global prevalence and risk of chronic or persistent pain among adults based on BMI. CINAHL and PubMed are two widely used and comprehensive medical databases and, thus, were chosen for this review. A search strategy was developed using combinations with the following MeSH terms: chronic, persistent, pain, associat*, overweight, obes*, and prevalen*. Asterisks were used to increase the search strategy; for example, ‘‘obes*’’ as a search stem returns articles with key words of both obesity and obese. Figure 1 is a
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Pain among Overweight Adults
PubMed: 977
CINAHL: 378
Duplicates Removed
Abstracts Screened: 65
Studies within Criteria: 9
FIGURE 1. - Flowchart indicating number of studies returned and screened.
flowchart indicating number of studies returned and screened. Studies were included if written between the years 2000 and 2016 in the English language, if data on presence of chronic pain among a population of adult males and females were available, and if numbers of adults with and without pain and corresponding BMI values below and above 25 were presented. This review limited analysis to overweight adults as a preliminary investigation, as this definition encompasses a greater percentage of the population than strictly obese; thus, articles that provided information on adults with obesity but not overweight were excluded. A total of nine research articles met criteria for review. Table 1 summarizes how risk and odds ratios were calculated.
RESULTS A total of nine articles were used to calculate risk and odds ratios of chronic pain diagnoses or reports among overweight adults as compared with adults with
normal weight. Sample sizes ranged from 736 to 24,450 participants. Studies were conducted in North and South America, Western and Eastern Europe, and Australia. All nine studies demonstrated an odds ratio greater than 1.0, though none was greater than 2.0, suggesting a moderately higher risk for reports of chronic pain among adults with BMI greater than 25 as compared with those with a normal-weight BMI. Calculated relative risk ratio varied widely among the samples and revealed that adults with overweight status had between 14% and 71% greater risk of reporting persistent pain than adults with normalweight status, with the average being 34%. c2 values were calculated and reached significance at the 0.05 level, except for one study where c2 ¼ 0.08. Table 2 provides more details including the definition of chronic pain that each respective study used.
DISCUSSION Populations with overweight and chronic pain reports are increasingly more prevalent and both conditions present multiple health risks. Data provided here support the findings of a relationship between chronic pain and an elevated BMI. Specifically, the risk for reports of chronic pain is greater for a person with a BMI greater than 25 than it is for a person with a BMI less than 25. Many studies also report that BMI is related to persistent pain in a dose-dependent way; in other words, risk for a chronic pain diagnosis increased as BMI increased above normal (Stone & Broderick, 2012; Wright et al., 2010). This is a clinically significant finding, although this was not a primary aim of the current literature review. One of the studies from this analysis had a risk and odds ratio that did not meet the 0.05 significance level for the c2 test, which could have been due to a relatively small sample size (826) focused on adults
TABLE 1. Risk for Pain Among Overweight Compared to Recommended Weight Adults Risk
Risk Ratio
Odds
Odds Ratio
Overweight adults þ pain/total overweight adults ¼ risk for pain among overweight adults Normal-weight adults þ pain/total adults with pain ¼ risk for pain among normal-weight adults
Risk value for pain among overweight adults/risk value for pain among normal-weight adults ¼ risk for pain among overweight adults
Overweight adults þ pain/ overweight adults without pain ¼ odds of pain among overweight adults Normal-weight adults with pain/normal-weight adults without pain ¼ odds of pain among normalweight adults
Odds value for pain among overweight adults/odds value for pain among normal-weight adults ¼ odds of pain among overweight adults
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TABLE 2. Calculated Risk and Odds Ratios for Reports of Pain Among Overweight Compared to Recommended Weight Adults
Study and Year Heuch et al., 2013
Fowler-Brown et al., 2013
McCarthy et al., 2009
Allen et al., 2016
Jakobsson, 2010 Vandenkerkhof et al., 2011 Lake et al., 2000
Ohayon and Stingl, 2012 Gouveia et al., 2016
Chronic Pain Definition National Health Questionnaire (presence of low back pain last 3 continuous months in previous year) Brief Pain Inventory and Joint Pain Questionnaire (pain in joints or all over on most days for past 3 mo or longer) Total Pain Index (moderate pain, >3/10, lasting greater than 3 mo) South Australian Health Omnibus Survey (pain lasting 3 of the past 6 mo) Survey (pain in last 3 mo or longer) Survey (widespread pain in last 3 mo per fibromyalgia definition) Questions from validated survey (pain in low back lasting $3 mo) Phone survey (pain lasting $3 mo) Self-report (presence of low back pain in past 90 þ days)
Prevalence of Overweight Status among Adults with Pain
Relative Risk
Odds Ratio
Total Sample Size
p Value (c2 Test)
Time 2: 4,349/ 6,848 ¼ 64%
1.14
1.196
24,450
<0.001
249/330 ¼ 75%
1.41
1.801
736
<0.001
273/424 ¼ 64%
1.21
1.483
819
<0.01
402/644 ¼ 63%
1.41
1.573
2,616
155/309 ¼ 50%
1.17
1.286
826
Time 2: 455/909 ¼ 50%
1.45
1.032
6,948
<0.001
409/1,021 ¼ 40%*
1.152
1.173
9,134
0.02
352/752 ¼ 47%
1.442
1.198
3,011
0.03
941/1,346 ¼ 70%
1.713
1.858
4,091
<0.001
<0.001
0.08
*These data indicate childhood and young adult body mass indexes for those who report low back pain at age 33.
18 years and older. In contrast, some studies suggest that age older than 55 years may present greater risk for comorbid pain and overweight conditions as compared with younger ages (Allen et al., 2016; Stone & Broderick, 2012). Other studies from this literature review with comparably small sample sizes were focused on the adult population aged 65 and older (Fowler-Brown et al., 2013; McCarthy et al., 2009), which could have contributed to the significant findings. Several considerations need to be made when interpreting the data calculated from this analysis. These include limited availability of longitudinal data, differences in measuring chronic
pain, lack of diverse geographical data, differences in BMI calculation, and BMI as healthy weight determinant. Limited Longitudinal Data Most of the studies selected in this review were crosssectional in nature, meaning that the variable of change over time is not considered. Thus, it is not clear whether chronic pain predisposes one to an overweight BMI or if the opposite is true. Two studies that fit criteria for this review did look at a group of adults over time with the question of cause or effect in terms of chronic low back pain and BMI. Heuch,
Pain among Overweight Adults
Heuch, Hagen, and Zwart (2013) followed a group of Norwegian adults for 18–10 years, and although they found no difference in BMI between adults with and adults without pain between time points 1 and 2, there was a significantly higher odds ratio for development of chronic low back pain at the 10-year follow-up for those with overweight BMI at time point 1 as compared with those who were normal weight. This lends some evidence to the notion that elevated BMI is a risk factor for future development of chronic low back pain. The second longitudinal study by Lake, Power, and Cole (2000) assessed data from the British birth cohort, in which all babies born between a few specific days in Great Britain were invited to join this life-long research effort. At ages 23 and 33, BMI and chronic low back pain were measured, and results revealed that women who had an overweight BMI at 23 had a significantly greater odds ratio of development of chronic low back pain at age 33 and gained an average of 1.1 kg (2.42 pounds) more than normal-weight females over the time frame. Men had similar risks, though calculated values did not achieve statistical significance. These data also suggest that higher BMI poses a risk for development of low back pain over time as opposed to the other way around, and though the sample with pain at time point 1 did gain more weight at time point 2 than those without pain, the number is clinically insignificant at only 2.42 pounds more than the normal-weight group. Regarding the impact of chronic pain on weight, a recent longitudinal study in England followed overweight adults with chronic pain who were attempting to lose weight, and after 1 year, the group with reports of severe pain lost significantly less weight (on average 11 pounds) than the groups who reported small to moderate levels of pain (Ryan et al., 2017). Thus, it appears that weight and pain self-management are barriers among overweight adults with chronic pain. Differing Chronic Pain Definitions The purpose of this study was to investigate risk for any type of chronic pain among overweight adults. However, many studies that met criteria for this review focused on one specific type of pain. Three studies, for example, focused on BMI among adults with persistent low back pain (Gouveia et al., 2016; Heuch et al., 2013; Lake et al., 2000). Another from this review limited pain measurements to chronic widespread pain, which defines fibromyalgia (Vandenkerkhof, Macdonald, Jones, Power, & Macfarlane, 2011). The remaining studies did not specify a pain diagnosis or location. Wright et al. (2010) differentiated pain types among participants and found that overweight adults
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had a greater risk for all pain conditions, but only abdominal pain, low back pain, fibromyalgia, chronic widespread pain, and migraines reached statistical significance. Thus, there is a need to perform longitudinal studies that report incidences of all types of chronic pain as relates to BMI to investigate whether populations with overweight have increased risk of development of all or certain types of chronic pain diagnoses. In addition, chronic pain was defined differently among the studies. Allen et al. (2016) operationalized chronic pain as pain occurring at least 3 of the past 6 months, whereas the rest of the studies defined it as pain lasting most days in the past 3 months (Fowler-Brown et al., 2013; Gouveia et al., 2016; Heuch et al., 2013; Jakobsson, 2010; Lake et al., 2000; McCarthy et al., 2009; Ohayon & Stingl, 2012; Vandenkerkhof et al., 2011). Limited Geographical Diversity of Study Samples Although this literature review was meant to explore the global risk and odds ratio for chronic pain diagnoses among overweight adults, no studies matching the search criteria were found that were published in countries in Asia, Africa, Middle East, Pacific Islands, or South America, thus limiting ability to generalize findings on a worldwide scale. Although the prevalence of overweight status and obesity is significantly lower in Japan than in Western countries, a recent longitudinal study was conducted among Japanese males that supported evidence that a dose-dependent relationship exists between overweight status and low back pain (Hashimoto et al., 2017). Prevalence studies among males and females are needed to examine the relationship between overweight status and chronic pain among diverse populations, especially in countries of low socioeconomic status (SES), as data is scarce regarding these conditions and treatment options in such areas. A meta-analysis suggests that overweight is a concern in countries with low SES (Dinsa, Goryakin, Fumagalli, & Suhrcke, 2012), and a cross-sectional study conducted among inhabitants of Iran confirms that people with obesity face increased odds of having chronic low back pain reports in this population (Noormohammadpour et al., 2016). However, it is unknown what current risks are for reports of persistent pain among adults with overweight status in countries outside of those mentioned in this report. BMI Measurement Body mass index was calculated through self-reported height and weight data in more than half of the studies included in this analysis (Allen et al., 2016; Jakobsson,
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2010; Lake et al., 2000; McCarthy et al., 2009) and was measured by professionals in the remaining studies (Fowler-Brown et al., 2013; Gouveia et al., 2016; Heuch et al., 2013; Vandenkerkhof et al., 2011). Self-report of height and weight may not be as accurate as professionally obtained values (Stommel & Osier, 2013). Studies are lacking to validate accuracy of self-report of height and weight among populations of adults with persistent pain and overweight status. In addition, the current literature review restricted the calculation of risk and odds ratios for presence of pain to overweight BMI, defined as 25 or greater, compared with adults with a BMI less than 25. Clinically, risk for adverse health outcomes is more commonly seen with an obese BMI of 30 or greater (CDC, 2017). Thus, a limitation of this review is the focus only on studies offering data on adults with overweight status as opposed to obesity. The clinical relevance of this review is the finding that compared with a norrmal-weight BMI, an overweight BMI was associated with greater risk for reports of persistent pain, highlighting the importance of weight management education of overweight and not only obese adults to reduce this risk. BMI as Healthy Weight Determinant There has been some critique of the use of BMI alone as a marker for disease. Researchers using the British birth cohort data analyzed differences between different anthropometric measures in correlating chronic low back pain, yet found BMI to continue to be a significant predictor, though total fat mass was a stronger predictor of pain (Heuch, Heuch, Hagen, & Zwart, 2015). In another study, chronic low back pain and association between BMI and body fat percentage were assessed in Japanese males, and although body fat percentage was found to be a better predictor of the relationship, BMI remained statistically significantly associated (Hashimoto et al., 2017). In contrast, a small study found that the use of BMI was a poor predictor of athletes versus non-athletes, as opposed to percentage fat mass, which was a highly sensitive predictor (Kruschitz et al., 2013). This lends question to the usefulness of BMI in determining healthy body composition and in screening for health conditions such as chronic pain. Future research should be conducted to derive the best measure of body weight to identify risk for persistent pain conditions. Implications for Practice Overweight status increases risk for reports of persistent pain in the global general population. Longitudinal studies indicate that past overweight
status is more important in predicting future pain than past pain is in influencing future overweight status. Implications for the pain management nurse include educating patients to achieve and maintain a normal body weight through proper diet and exercise, as this may help adults reduce risk for reports of persistent pain. Achieving and maintaining a recommended body weight will also reduce the risk for adults with persistent pain of developing obesity-related medical conditions such as diabetes and heart disease (CDC, 2017). According to the American Heart Association (2016), adults should be encouraged to engage in a minimum of 150 minutes of moderate-intensity aerobic exercise each week for cardiac health benefits. A meta-analysis of weight loss studies among adults with chronic low back pain revealed that swimming, yoga, and weight-training exercises were the most effective in safely facilitating weight loss and improvement in pain intensity and pain disability in this group (Wasser, Vasilopoulos, Zdziarski, & Vincent, 2017). Thus, nurses can educate overweight adults with pain to incorporate 150 minutes per week of one of these kinds of exercises into their daily routine for improved pain and weight health outcomes. Research suggests that exercise alone is not significantly effective in producing improved weight and pain health outcomes among overweight adults with persistent pain; rather, combining exercise and a proper diet is most beneficial (Kumar, Beavers, Devita, & Messier, 2017). National dietary standards were recently published and are important for nurses and patients alike to read and follow (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). One method of encouraging adults with pain to follow a balanced diet to facilitate weight loss as recommended by national standards may be through promoting the use of an electronic food diary which calculates total daily calories and macronutrient information based on the foods and servings input by the user. Evidence indicates that the use of mobile applications to track food intake and activity levels leads to greater weight loss than traditional methods alone (Spring, Duncan, & Janke, 2013). Several such free applications exist; a quick Google search with the terms ‘‘food diary apps’’ returns nearly 1.6 million results. Many nutrition applications offer a built-in macronutrient calculator to allow the user to indicate personal height, weight, and activity level, and based on these data, unique daily caloric and macronutrient needs for weight loss are calculated. However, the use of such applications has not been thoroughly tested among adults with persistent pain diagnoses. In the
Pain among Overweight Adults
light of the growing obesity and chronic pain epidemics, more education for the general adult population on weight self-management may be indicated to mitigate the prevalence and impact of persistent pain.
CONCLUSIONS The studies conducted among individuals aged 15 and older have indicated, both in cross-sectional and in large, longitudinal designs, that there is a relationship between chronic pain and overweight status. Longitudinal studies suggest that overweight status is more important in predicting later or
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recurrent chronic back pain as opposed to chronic back pain contributing to weight gain and overweight status over time. The relationship between weight status and pain is not well known other than for low back or osteoarthritis conditions (CDC, 2017). Few studies to date have investigated whether moderate weight gain that does not reach criteria for obesity can influence pain. Given the dearth of global studies that associate overweight status with persistent pain, it will be prudent to collect more high-quality, longitudinal data to further investigate this relationship, especially in countries where there are no well-documented data on this phenomenon.
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