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Supplement and Medical Nutrition Therapy Guide

Part of the Clinical Practicum series on WholisticMatters designed to bring you clinical information for your practice.

 Pain and Inflammation

Dietary supplements are one of the most common integrative approaches utilized for pain management. On average, more than half of individuals with pain use dietary supplementation as a treatment strategy, with the percentage being higher in certain chronic pain populations.

The following article will provide an overview for practitioners of how to view and optimally utilize foundational and advanced dietary supplements for reducing pain and inflammation.

Begin with the Diet

While dietary supplements are often seen as a quick fix for pain, it is important to put this in the background of an individual’s diet to maximize results. For example, an anti-inflammatory diet when combined with fish oil supplementation will have a much greater impact in the setting of certain arthritis than when fish oil supplements are added to a Standard American Diet, which is often association with chronic inflammation. While supplements can have a powerful impact on inflammation and pain, they should be introduced after practitioner and patient review together how to optimize the patient’s diet.

Medical Nutrition Therapy

In some cases, medical nutrition therapy is considered as an option and seen as situated between diet and supplements. Medical nutrition therapy often contains mixes of micronutrients (vitamins, minerals, and other dietary supplements) along with macronutrients (proteins, fats, and carbohydrates) in various combinations to meet conditional needs. Medical nutritional therapies, which are often categorized as functional foods, can be especially helpful for cases where more comprehensive nutrient support is required to address cases such as elevated toxin burden, obesity, and inflammation. A practitioner will decide if functional foods are needed as part of a patient’s program and, if needed, the frequency and length.

How to View Supplements

As a practitioner begins to consider supplements, it is important to work with the patient to incorporate formulations with which the practitioner has had positive experiences. In addition, the benefit of the supplements is often related to individual needs. This is because supplements can work on multiple levels which may be more pertinent for one person than another. In some cases, they may work on multiple levels at once and finding best-fit supplements can help derive maximum benefit. For example, supplements can provide support for areas including:

  • Nutrient deficiency
  • Inflammation
  • Oxidative stress
  • Toxin load
  • Mitochondrial dysfunction
  • Gut dysfunction (dysbiosis)

The following listing reviews several foundational supplements which may be prudent for most cases of pain. A follow-up article will review additional supplements for selected cases of pain.

Foundational Supplements

Vitamin D

Vitamin D deficiency is prevalent in pain populations and may worsen pain status. In a study of more than 9,000 participants, those with low vitamin D reported more frequent and severe back pain, with higher limitations in their daily activities. Adding vitamin D to current pain treatment appears beneficial. A study which added 100 mcg (4,000 IU)/day of vitamin D reduced daily pain and need for analgesic medication compared to placebo. In addition, several inflammatory markers were reduced by 40 to 50 percent in the group treated with vitamin D.  The dosage of vitamin D is most commonly based on testing and is typically 50 mcg (2,000 IU) or more per day. Vitamin D has also shown to improve the effectiveness of other medications in the prevention of migraine headache.

Magnesium

It is estimated that 68 percent of Americans do not consume the recommended dietary allowance (RDA) for magnesium. Magnesium deficiency has been associated with inflammation.   With magnesium being involved in over 300 reactions in the body, deficiency has been linked to higher rates of inflammation, pain and headache, depression, fatigue, muscle spasm, and insomnia. Importantly, replenishment of magnesium through supplementation is quite effective in reducing deficiency. In one study, those receiving magnesium over six weeks versus placebo had reduced pain intensity and improvement in low back movement ability during a six-month follow up period. Practitioners should be advised to titrate magnesium dose to the patient’s stomach tolerability. Plant-based, multiform magnesium may provide superior absorption.

Omega-3s

Analysis of intake for omega-3 fatty acids in U.S. adults notes that most do not have adequate intake of these anti-inflammatory fatty acids including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Several studies have noted that marine-derived omega-3 polyunsaturated fatty acids supplementation can provide significant reduction of inflammatory markers (CRP). In the setting of specific pain states including lower back and joint pain, trials incorporating omega 3s have noted reductions in pain and medication requirement. Practitioners may recommend dosing between 1000mg-3000mg of combined EPA and DHA, which are typically utilized in this setting. Omega-3s, when added to medication, have also shown benefit in the setting of migraine headache.

B Vitamins

Several B vitamins have been linked to pain. The best example is vitamin B12, where deficiency or functional deficiency (defined by elevated levels of the B12-dependent metabolites, methylmalonic acid (MMA), and/or homocysteine, despite normal B12 values) has been linked to pain states, including neuropathy. Testing pain patients for B12 deficiency is prudent.

In general, pain patients should be recommended to supplement their diet with a foundational B vitamin complex with additional higher doses of B vitamins being used in certain clinical scenarios.

Secondary Benefit of Nutrition

In many cases, the above nutrients, in addition to providing benefit in the setting of pain, may provide benefit for comorbidities often encountered by pain patients such as depression, fatigue, and cognitive decline. For example, magnesium has been shown to significantly improve depression with improvement being more significant in those who are deficient.

Synergy of Co-factors

Many supplements which may not be regarded as independently important in reducing pain are actually quite important in supporting this effort. For example, calcium and vitamins A and B6 have been shown to act synergistically with magnesium to reduce pain, inflammation, and depression. Similarly, carnitine has been shown to be beneficial in supporting the benefit of co-enzyme Q10 and other antioxidants in reducing inflammation. This is because these nutrients often act as co-factors that allow improved absorption, balanced uptake, and utilization of the foundational supplements. This is one of the reasons that several formulas may include important cofactors that allow a individual’s foundational supplements to work optimally.

Advanced Supplementation

Beyond the foundational supplements noted in the previous section, a number of specific nutrients and herbal and non-herbal supplements may be helpful in certain settings. The following tables summarize some of the foundational and advanced supplements that may be helpful in the setting of headache, metabolic pain, and joint pain. As dosages, especially herbals, vary based on preparation, it is important for practitioners to closely follow their team’s recommendation on formulation and dosing. A few examples of advanced supplements a practitioner’s team may recommend include:

Curcumin

Curcumin is a component of the spice turmeric. Similar to omega-3 fatty acids, curcumin can promote a strong reduction in inflammation – typically at 1,000 mg per day. In one analysis, curcumin caused a significant two-point reduction in the 10-point visual analogue score for pain in those with knee arthritis. In other trials curcumin provided similar pain relief when compared to traditional anti-inflammatories.

Ginger

Ginger is a traditional herb in many world cultures that is similar to curcumin and can provide inflammatory support. In addition, ginger has been found to help reduce gastrointestinal (GI) symptoms associated with gastritis and ulcer formation. Lastly, ginger has a long history of helping to reduce nausea. Ginger is an ideal herbal to support those who are regularly using anti-inflammatories for their pain and have associated GI symptoms, such as those with migraine headache. Ginger dosing is typically 250 to 1000 mg per day.

Probiotics

Probiotics are supplements that support the microbiome and the microbiota that make up the GI tract. There are numerous types of probiotics, such as Lactobacillus and Bifidobacterium species, which have shown benefits in various pain and inflammatory settings. Probiotics are typically considered after several of the “Rs” including Removing, Reducing and Repairing before initiating re-inoculation. Based on this, probiotics should be started after careful consideration with the practitioner’s team and typically with trusted formulations that provide several billion units (CFUs).

Selected Supplements in the Setting of Headache and Metabolic Pain

CoQ10
Vitamin D3 Dosing typically based on patient levels
Folate/B12
Black Cumin Seed  Antioxidant effects and glycemic control
Cruciferous Supplement Acts as a glutathione precursor
Omega-3 (EPA/DHA/DPA) Background diet is key
Chaste Tree

and/or

Kava

Supports Melatonin

 

Sleep Quality

Magnesium Whole plant-based multiform

 

Selected Supplements in the Setting of Joint Pain

Curcumin Ensure enhanced bioavailability formula
Boswellia Standardized to boswellic acid
Ginger Based on activity of supplement and patient ability to tolerate (GI side effects possible)
Glucosamine
Enzyme formula containing Bromelain May be helpful in reducing swelling

 

Supplements for Gastrointestinal Support in the Setting of Pain

Probiotic Look for multi-strain products containing at least 4 billion units (CFU) of beneficial strains including: Saccharomyces boulardii, Lactobacillus and Bifidobacterium
Prebiotics

e.g. Inulin

Support digestion, nutrient absorption and metabolism
Betaine HCl Supports digestion and nutrient absorption
Choline Supports methylation and digestion
Ginger Based on activity of supplement and patient ability to tolerate (GI side effects possible)
Berberine Can be helpful in reducing bacterial overgrowth and elevated blood glucose
Rosemary Supports digestion and cognition
Bitter Melon Supports digestion and glucose control
Cinnamon Supports digestion and glucose control
Gymnema sylvestre Supports reduction in blood glucose and carbohydrate consumption

 

Dietary supplements have an important role to play in human health, especially in the setting of reducing deficiencies, inflammation, and pain. It is important to evaluate background diet and the formulations being considered to maximize benefit from any dietary supplement regimen.  After reviewing a patient’s triggers, the practitioner will provide detailed suggestions for using diet, medical nutritional therapy, and supplements during the patient’s program as part of their diet therapy plan for managing pain.

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