Lessons Learned: Jenifer Tharani, MS

Hello everyone, I'm Dr. Darsha Shah, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined, a podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. Before we get into this lessons learned, here's a quick message from our sponsor, MR Insurance, a small business that helps physicians with their disability insurance needs. Michael L. Velras is a CFP professional and insurance agent committed to helping physicians nationwide with their term life and disability insurance needs. He provides an objective, transparent, and education-focused process that aims to help physicians make prudent decisions and avoid over-complicating things. He exclusively offers own occupation and disability insurance policies for residents, fellows, and attending physicians. We know he'd be happy to help you with whatever your needs are. You can find Michael at Dr.Potcastnetwork.com for slash MR Insurance, or contact him at 800-817-4522. And let's get to the episode. All right, hey everyone, welcome back to another episode of Medicine Redefined with me in Ultimash. Today we are giving a lessons learned on chronic pain nutrition with a recent guest, Jennifer Torani. It's Ultimash. Where do you want to start with this? What did you take away? It was a cool discussion, man. I definitely learned a lot. I mean, I think she has a very challenging job. Nutrition in itself is such a complex thing. We've spent quite a bit of time on this show talking about it. And lately, we've been talking a lot about pain and pain just in itself. I think we've kind of scratched the surface on and how we're understanding it. And so it's admirable that she's attacking these two different but interrelated complex phenomenons and trying to just make people's quality of life a little bit better. So it was quite impressed. Yeah, absolutely. It's definitely a cool topic, right? I kind of mentioned that there's nutrition, but then you can even get specialized in dealing with chronic pain nutrition, which I don't think many people really realize. What did you take away from her journey and her story? So just the inspiration, kind of, what stemmed her to go down this route, right? I remember her talking about essentially when she was a little girl and her mom going through the battle of, I think it was rheumatoid arthritis, that she was mentioning and she wanted to go to these parties or the South Asian weddings, which are a couple of days long. And her mom couldn't always make the trip or couldn't always go to the movies. And, you know, as whatever, like maybe she never said how old she was. But if you're a 6, 7, 8-year-old girl, you don't really understand that. And of course, as a parent, you're always sheltering your child from your own pain, right? And so, like, literally, in this case, your pain, but also any concerns and stresses that you might have, because you don't want to put that burden on your child. So, actually, like, that spoke to my heart. Like, I can't imagine how difficult that must have been for her mom. And then she said ultimately her mom would just take some type of pain medication or whatever and just kind of, you know, get the strength and go out to the movies. But as she got older, she started to really appreciate, hey, you know, you can see the pain. You know, it's a little bit harder for my mom to get up and come out and play and stuff. And I think we've talked about this in some capacity before and, you know, why it's important to continue strength training, why it's important to continue being healthy in your later years when you're 50, 60, 70, not necessarily with chronic pain. But as you age, you put some mileage on those joints, you know, things start aching a little bit. I think we're both north of our 30 now and sometimes, unfortunately, you know, we'll wake up and we'll feel a little north of 30. And so, that can take a little more. I got two years on you. All right. I got two years on you. Oh, you're not. Yeah. I'm 28. I'm about to 29. Oh, my God. I'm putting you in the future. An old man. Yeah. Yeah, it's definitely. So, I think that one was definitely something that struck a chord with me for sure. What about you? Yeah. Absolutely. No, I think our stories make us who we are, right? I mean, look at us, why we went into PM&R and our stories with pain and our own physical journeys as athletes and things. So that was definitely really cool to see. One of the things she mentioned was a dietician versus a nutritionist. Now, this is something I had no idea about, you know, and I kind of used it interchangeably. But it's really cool to see that a dietician is a protected name. So they actually go through more board like qualifications and more degrees. Some of more of a higher level of education, whereas anyone can, anyone can call themselves a nutritionist. So, you know, very important for those out there that, you know, look at Instagram and follow a lot of people. People out there giving advice, right? And there's a lot of misinformation for sure. So one of the things that we look for is, hey, is this person a dietician? And if they are a nutritionist, what kind of qualifications do they have? So just the heads up to everyone there. Yeah. Super important. I mean, you know, in some capacity, I think, you know, labels and titles, they don't mean a lot, but at the same time, you want to make sure you're seeing the appropriate healthcare professional for whatever your concern is. For instance, I think specifically she had mentioned that nutritionists can't do medical nutrition. Is that right? I think so, yeah. I think one of the distinctions that she talked about. And so this chronic pain, I mean, this is a medical diagnosis, right? Whatever the reason might be, it could be cancer related pain, it could be pain from low back pain, it could be fibromyalgia, it could be a specific rheumatoid condition. But so that's an important point to remember. So I like that. What else? Anything else stuck with you? Go ahead and talk about acute pain versus chronic pain and the specific markers that she uses, right? So, you know, for those in the healthcare field, you guys might know about, you know, a said rate ESR or CPR and using those markers as inflammation, but not only using the objective data, but she also looks at lifestyle factors, you know, whenever she implements whatever strategies of its medication, if it's food, looking at not only just those markers, but hey, does this person have more energy? Are they sleeping better? Are they able to, you know, live the life to their fullest or so to speak? And I think that's just so important for us doctors to realize, you know, oftentimes we treat a number, right? We see a blood pressure and we're given that anti-hypertensive or we see whatever it is, the sugars or something, but sometimes we need to take a step back and say, hey, we need to treat the person, right? And look at the lifestyle factors altogether. So that's just that kind of strong color with me there. For sure. Yeah. No, I think that we've kind of talked about the definition of just acute versus, I mean, we've described it in multiple different ways. And I like how she touched on inflammation as well as you've kind of alluded to before. It's important to understand, you know, what exactly is happening in specifically the pathology, because if you don't know the underlying mechanisms, then you're kind of just, you know, throwing some darts and just hoping, like, you know, something sticks, I guess I'm mixing analogies here, but you threw stuff at the whole and hoping something sticks. So, you know, identifying the triggers is something that also that she had mentioned is really, really important, right? I think I use the word flare-ups, I'm not really sure if she liked that or not. But essentially, the way I understand it is, you know, whatever the pathology is, whatever the dysfunction is, you need to identify the root cause where we go back, this is something that you love, right? Identify what's causing the actual dysfunction, what's causing the painful situation, the condition, and obviously the no-brainer situation is to avoid it. But maybe that's what her mom was doing, but at the same time, if you're avoiding it and that's impairing the quality of life, how can we help maximize that? So, one of the strategies that she had talked about is, you know, using elimination diets. Now, I don't know, I had mixed feelings about this, right? So, what I did like about it is that, like, I go back to, I keep going back to this erycristic code about it, if you're not assessing, you're guessing, right? You need to know what it is that is the trigger in your food that's specifically causing you to feel the way you're feeling. Is it dairy? Is it gluten? Although, you know, you talked about how that might be a little bit overhyped, but, you know, in her world, people who have non-celium gluten sensitivity is a very real thing. And so, you really need to figure out how to do that. And I think she had mentioned that the literature supports to kind of do these complete elimination diets and slowly introduce food back and try to figure out if you have quote unquote sensitivity or not. The reason I'm kind of on defense about that is because I don't really know how effective that is. I had asked her specifically, is like, would it be better to perhaps eliminate one food at a time to see how you feel? I know her point of view that, you know, you're trying to get quote unquote good. You're trying to get the person well as soon as possible. And then you want to see like, okay, which is going to actually, you know, be the trigger. But to me, this is a question of that question that we're always talking about in healthcare and nutrition is the question of efficacy versus effectiveness. I think it would be much more effective if you put the individual in the least possible restrictive diet. Like I think that whole 30 is the classic example. Super popular. I think there's nothing wrong with it. I mean, I'm a proponent of it. I don't, if I completely truly understand it, but I think what my understanding is correct me if I'm wrong. It's like, it's just a whole food based approach. You're limiting alcohol. You're eliminating like any, you know, I don't know, tell me more about it. Like I think what kind of, I know you can have meat, but I'm not, is there specific type of meat that you can have or like, is it like only grass fed beef and that kind of stuff? I could be wrong. Yeah. So I'm looking at it now. So elimination diet of sugar, alcohol, grains, legumes, soy, and dairy. So it's similar, but more restrictive than the paleo diet actually. So you can't even have like natural sweeteners or at least some of them, some restaurants don't do that. So stevia, stevia is no go. Yeah. So stevia is no go. And then you can also can't do like honey and maple syrup for some of them. So it's actually pretty restrictive, but yeah, I guess, you know, in that sense, you're really taking out a lot. But this is, it's interesting, right? Like so I have eczema and I've no idea how my eczema got triggered, but now I'm trying to see how can I get rid of it and I know food is a huge, huge part of that. But it's really difficult to kind of just eliminate one whole category. And you know, sometimes you often have to figure out, is it a fruit? You know, what if I just take away apples for three, four days, see how it works, right? Or let's try banana. Okay, maybe it's not a fruit. Let's try complex starches. If it's not that, let's try these sweeteners. So I think, you know, if I were to eliminate everything, I don't really know if I'm really getting an answer. Sure, I might get better, but how do I start to add back the things, you know, that I know work when I just know that eliminating all of it, right? And I think we're starting to realize that food works very synergistically. There's actually a study out, I think in Sweden or something, about diabetes and trained diabetes and they're starting to put programs together, meal programs where different food combinations are actually seeing better effects with glycemic control. So it's super interesting. But yeah, I definitely agree with your point here. Yeah, I think that's the key point that you made, right? The food works very synergistically and it's so interesting because this is such a vital thing that we've done for millions of years. We're always eating. We're always sleeping, but we have very limited understanding of why and how and the underlying mechanisms. And so I love that you said that. And again, because it's so polarizing, we talk about it. Your point about that the synergistic component, like in terms of, I remember first reading John Brody talk about this, you know, at least in precision nutrition, when he's a co-founder, they try to recommend not consuming fats and carbohydrates, like high fats and carbohydrate meals together, because that contributes like, I mean, you know, if you're, like, for instance, okay, Dr. Arnt came on talked about, you know, your post workout meal, you want to have carbohydrates because you're getting the non insulin dependent uptake, right, into your muscles. But then also, like that's when you're really insulin sensitive, so you're going to put it in the right place. You're not going to, your liver is going to be insulin sensitive, your muscle is going to be insulin sensitive. Your fat is also going to be insulin sensitive, right? So you don't want to put triglycerides in that region, and that's kind of probably the reasons why I like you want to put fat fats and carbs at the same time, you know, I think I hope that I'm saying that correctly. So yeah, so that's a big one, man. Yep, absolutely. Let's see. Other things here that I really liked was her explanation about eating patterns versus diets, right, and how she approaches her clients. So just like how we had EC Cinkowski on here talking about how diet and the word diet is very restrictive, right? There's a stop date and an end date. And rather than that, what we want to do is promote eating habits and eating patterns. So you know, that was, that was definitely something that I really liked. I love that. I love the term that she used that and she says, I think when we specifically asked her diet and she said, what exactly, like, you know, when people think diet, they think it's start and a stop, right, it's, it's a finite amount of time. And sure we have a finite amount of time in this life, but you're probably going to continue to eat for until the end of time, whenever it is, hopefully those last days are healthy and it's not like cancer or something when people aren't, don't want to eat and don't much have an appetite or anything like that, but people, I mean, it's, it's necessary for survival. And so it's, it's a lifestyle, right? It's kind of lame. It's a cop out and I don't, I don't necessarily love that, but, but I, I, I, it's just, you know, the semantics are, I do think are important because when people say, okay, again, new year, new me, new diet, it's like, okay, well, how long is that going to last, right? So yeah. And that thing, you talk again about E.C. Sinkowski. This is one of the reasons we're such big fans of her because she's always talking about sustainability. She's talking about mastering the basics. And this brings me to the next point when I specifically asked her about, hey, give us some, maybe perhaps some case studies about when somebody might have diabetic neuropathy because she works in an endocrinology clinic versus knee osteoarthritis and an overweight individual. And I don't remember her saying that there really was a difference. Really was just geared at focusing on the basics and mastering the basics, you know, drinking water and nothing that's really extravagant, nothing that's super sexy. But that's exactly what separates the successful from the unsuccessful is hammering the basics over and over and over again. I'm sure I stole that quote from somewhere, but, um, did I? Is that all right? Hello. I don't know. I haven't heard that. No, that's definitely not mine. Probably. I agree with you. I think you look at any field across the board, right? Like anything. If you want to be going to finance or medicine or technology, computer science, right? It's all about mastering the basics, right? I think a lot of people get too fancy and try to do the cool thing out there before mastering the basics, right? Even in sports, you master the fundamentals. And that's how you elevate to greatness. And it's no different with living a great lifestyle. If you want to increase your health span and lifespan, you've got to master the basics. And once you do that, sure, you can start to experience little things and see where you can optimize. But, uh, got to get those fundamentals down. I love it, man. Now we're starting to sound like an underarm, a commercial right now. Still that from somewhere, too, I guess. Maybe a little cum sponsor us. Well, it's interesting because earlier today, I was actually going through, uh, my wife was, I mean, they was kind of cleaning the house and it was shedding through some stuff. And I don't know why a payment are still sends. And for those who don't know, that's our parent academy. They still send us these journals and it's nice to have. They look cool, but it's just a waste of paper and I was like, okay, well, I just kind of flipped through it. And actually the 2020, December, 2020 version had this really cool narrative review talking about chronic muskiscotl pain and nutrition. Where are we and where are we heading? So I'd love to talk about that. But I wouldn't say if it was anything else that you had that, uh, from the interview with Jennifer. Well, let's do it. Let's get into it. Yeah. So it was a really cool paper and we'll link to, uh, in the show notes here for how do you recommend that I actually texted my co-chief to see if we can do that for journal club, uh, during our pain month coming up. And you know, the proposed mechanisms for chronic pain, um, and chronic muskiscotl pain and nutrition they talked about. So the one of the first things in Jennifer touched on a lot of this was inflammation, right? They're discussing about how tissue damage leads to this mass inflammatory, uh, mediator release, like, you know, we have serotonins, histamines, birdie kinens, cytokines, we talked about CRP. We talked about prostaglandins and leukotrines as well as thrombocsines, right? And these all specific ones have the ability to activate no susceptors in our body, which makes her us more sensitive to pain, right? In fact, a lot of the literature that they had referenced said that, you know, the CRP had a linear correlation to pain. So she mentioned, right? When we asked her what specific inflammatory markers, CRP is one of them. We know it's an acute inflammation, uh, inflammatory marker and in disease states, like infection and stuff, it's going to be elevated and even other ones. But, um, so it was kind of interesting to see that, that, you know, there's a higher pain intensity and these mechanisms might be a play. So that was kind of cool. Yeah, that's super cool. You know, I'm not, I'm not surprised, but it's cool to see that because I didn't know that. It makes a lot of sense. And again, the body's so fascinating, you know, and then the more we start to uncover these things, I think we can really start to take action against it. But yeah, that's super cool. And then just relate it back to what Jennifer was talking about right about supplementation. So we kind of got into, you know, omega-3s and turmeric and magnesium. And so you'll be proud of me, but I finally mailed in my omega-3 index yesterday. So nice, you know, waiting to, waiting to see what that is. And yeah, it's going to be interesting because me as a vegetarian, you know, like sure, I try to get my chia seeds and, and sources of omega-3, but we know that the conversion is not great, right, until omega-3. So probably we'll have to look into supplementation I'm assuming. But her whole turmeric thing was, was very interesting too. Yeah, yeah. I mean, so turmeric is an interesting one, right? I mean, it comes from, well, the interesting thing that I think about it is in terms of the mechanisms to hyenediracts. What's funny about, actually, there's another study that I was looking at recently, looking at turmeric, and it's ability to mitigate doms, delayed onset muscle soreness. There might have been an interesting one, curcumin, specifically, I think for my interest has been for osteoarthritis. I think that it's getting better and better in terms of what we're looking at. Last two years ago, me and one of my core residents, one of my previous chiefs who were looking at doing turmeric for neuropathic pain, people do it for turmeric for all kinds of reasons. We know it, I think we consider it to be maybe a super spice, not necessarily a super food, but, you know, the mechanisms for that are quite interesting as well. But another one, since we were talking about the inflammation war, they discussed how in animal studies, there's this natural chemical called limiting, have you ever heard of that? I don't know, I can be quite limiting. Yeah, but basically it's in citrus fruits, right? So we're talking grapefruit and oranges, and not a huge fan of oranges, maybe more tangering guy. But it decreases basically mechanical sensitivity by inhibiting, again, those pro-inflammatory cytokines such as interleukin one and TNF alpha, and another one, this was interesting because, again, us being, you know, guys and getting a start, me getting a start in the fitness industry where soy was like villainized for being estrogenic and whatnot, and they talked about how soy containing diet prevented hyperlogyza and heat aledinia. So I think that's super important, because we know that, you know, the central sensitization theory for pain, people have this increased sensitivity to pain, and a lot of times they get hyperlogyza, and they get aledinia as well. Do you remember what that is? Yeah, yeah. So for those of you guys listening, if you want to check out Patrick Finance episode, which is where we talked about this, right? So hyperlogyza, in medical school, we think of like the q-tip test, kind of, right, where if I take a q-tip, which should not induce any pain, normally it will cause a response of pain in some way with aledinia. Yeah, absolutely. I mean, so that's super interesting to understand. So I thought that that was just the inflammatory component. Now, I don't want to, like, we're definitely going to link to it so people can look at, it's all the underlying mechanisms that they kind of touched on in some of the proposed theories, but some of the other interesting ones that I think that I had never heard about. So I kind of touched on the central sensitization as well. The obesity one, I think that's pretty intuitive for most people to grasp. I'll touch on that because we kind of talked about osteoarthritis theory. You kind of just touched on curcumin is that's such an important one. Again, with nutrition and obesity, is it like, is it the weight loss that tends to help or is it the specific, excuse me, the specific nutrition that tends to help? But at the end of the day, I don't argue who cares, right, I mean, we know the literature at least what they quoted saying that obese individuals, compared to healthy individuals, are anywhere from 68 to 254 times more likely to experience chronic pain. I mean, that's pretty remarkable. An overweight individual is up to 20%. I mean, just looking at knee osteoarthritis specific thing, we know that the knee can take seven times more load. And so one of the primary interventions that we'll do with somebody with osteoarthritis is going to be weight loss, right? That's going to pay dividends down the road. But other cool things that they had talked about, this is an interesting one. This one ties back into our conversation with Patrick a little bit. They had talked about the homeostatic balance balance and the activation of the ventral striatum and the medial prefrontal cortex circuitry. Basically increased activity in this part of the brain region was associated with higher pain density in people with low back pain. What's also interesting is people with chronic pain that talked about are more likely to overconsume sugary foods than healthy people. Why? Because again, alterations in this part of the brain influence our eating behaviors by changing the hedonic value of specific foods. We know that sugar gives us that dopamine rush. It gives that positive response. And also stimulates our endogenous opioids. Here we go back to about stimulating the endogenous opioids. And if you can get your own body to give you the same hit as morphine or cocaine, maybe you don't need to take your oxy or morphine and cocaine, not promoting any of it. But I'm just saying, right? I mean, I just thought that was like really, really cool. Here's another one that's fascinating for you. Sorry, I'm just being at facts, but they've even talked about how sugar containing foods have the ability to increase pain thresholds in children undergoing vaccinations. In fact, some hospitals will give children sugar water prior to getting vaccinated. So the needle will affect them as much. Isn't that crazy? I've heard of that. Yeah. Did you? I don't know. I get to talk to my wife about that. See, that's a little trick that they're doing. I know before vaccination or shots and stuff, they're looking at a breastfeeding session before can also reduce pain because the oxytocin and just, you know, having that physical touch with mother can also do it. And then I've also heard the sugar, sugar water before it's interesting. Yeah. Yeah, I mean, I think that the oxytocin, or that's probably a better way to do it than getting the giving the kid basically a kid of, this is the reason for obesity. Yeah, here's a quick hit for a dopamine hit before you go. I do that. So I think that was really, really cool. I mean, they talked a lot about a homeostatic, aesthetic balance talking about how altered pH levels when you excessive, with excessive consumption of meat can cause increased lactate and pH actually cause irritation to the nerve roots in the introvertibular discs as well. So, you know, that's another mechanism for chronic low back pain, really cool stuff to check out. So I don't want to just kind of dissect the whole paper here, but I thought that you'd really find that fascinating. Yeah, it all definitely works. Something worth sharing. Cool. Yeah. Awesome. Anything else? I thought I think we nailed most of it. Again, it's just an awesome episode. Jennifer went through a great overview in terms of what a dietitian would do, especially in chronic pain. For sure. No, I agree, man. I think that there was a lot to learn here. I think the last message that I would like to leave our listeners with is this is something that we have to start paying attention to. I know that we do in the sense that sounds like we're considering, I feel like all the debates and nutrition all day every day, but specifically for chronic pain, I think that us as physiatrists and us, you know, our pain is such a prevalent thing in our population. In fact, that's majority of what we end up seeing. Somebody comes in with some type of pain, but I would urge our colleagues that we need to start talking to them about the nutrition. What are they putting in their bodies? Because I mean, it's definitely correlated and it's most likely causative as well. And if we can make some interventions and, you know, we talked a little bit about magnesium and supplementation with them and, you know, central sensitization, there's quite a bit of literature showing that magnesium deficiencies can actually increase sensory sensitization and, you know, how they act as these NMDA receptor blockers, which, or is it activators? I don't know. There's some relation to NMDA and that can be therapeutic for pain as well. So I think that this is really, really important for us to understand, especially if you're ever going to deal with somebody with chronic pain, which most of us are because it's so prevalent. Absolutely. I'm with you on that brother, 100%. Love it. All right. Hi, man. Until next time. All right. Sounds good. We really hope you enjoyed that lesson's learned and our takeaways from our discussion with Jennifer. But before we end, do not forget to reach out to MR Insurance Consultants where their goal is to assist physicians in obtaining the most comprehensive coverage available to fit their unique situation. Reach out for both excellent and quality service at doctorpodcastnetwork.com, 4 slash MR Insurance. And just time for that quick disclaimer, everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient relationship is formed and anything discussed in this podcast is not representative use of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health related issues. Until next time, take care.