Obesity Hurts: How To Approach Weight Reduction, Diet And Nutrition For Pain Management With Anneleen Malfliet, PT, PhD

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Obesity Hurts: How To Approach Weight Reduction, Diet And Nutrition For Pain Management With Anneleen Malfliet, PT, PhD

We explore how overweight and obesity are linked with persistent pain and the importance of physical therapists promoting combined nutrition, exercise, and weight loss programs when treating chronic pain syndrome. Joining us as an expert guest is Anneleen Malfliet. She is an Assistant Professor, Postdoctoral Researcher, and a member of the Pain in Motion international research group. Research in clinical investigations centers on chronic pain with a special interest in spinal pain, central sensitization nutrition, and diet.

In this episode, we will explore the broader lifestyle perspective when considering the link between obesity and chronic pain, how a clinician can assess the presence of obesity or be overweight. Finally, how to approach weight reduction and organize a weight management program in clinical practice. There is a lot packed into this episode. You will gain a lot from the information and data that Anneleen has around the impact of obesity on chronic pain. Let’s begin and meet Anneleen Malfliet.

Anneleen, thanks for joining me for this episode.

Joe, it’s great to be here.

I have been so excited to talk to you. You had a great paper coming out that would support this important topic, so much of the amazing work that you are doing as a physiotherapist and a researcher. Off the top of the episode, I want to point people to the paper that we are going to be talking about that supports a lot of your work. That paper is called Obesity Hurts: The Why and How of Integrating Weight Reduction With Chronic Pain Management.Everyone can access that. It’s an open-access article in PTJ, which is Physical Therapy Journal. That’s in the August 2021 edition of PTJ. Great perspective paper. Lots of useful information in there for not just physical therapists but other practitioners who are working with pain. Before we dive into that paper, I know you a little bit and we have collaborated on a project but I want to share your information and what you are doing in pain specifically. Tell us who you are and what you are doing in the research realm.

I’m affiliated with the Vrije Universiteit Brussel, a university in Brussels, the capital of Belgium. I’m working there within the Pain in Motion research group, which is a group focusing specifically on chronic pain very broadly. For most of my time, I have been specializing in chronic pain rehabilitation. I’m even refining the focus on the role of nutrition, diet, overweight, and obesity in chronic pain from both fundamental and rehabilitation perspectives, which explains this paper published. That’s what I’m focusing on and what I want to go further in.

You are a physiotherapist by training, went into research, focusing on pain management, and then you have this line, focusing on the nutrition aspect of chronic pain management. You lead a group around that topic.

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You cannot set physical activity apart from nutrition, especially if people are obese or overweight.

Within the Pain in Motion research group, we have different research lines. I’m responsible for the line specifically focusing on diet and nutrition in chronic pain. We have two PhD researchers involved in that area.

One is Omer Elma He has been on a previous episode. He’s done some great meta-analyses and some other papers on nutrition and pain. This is interesting to a lot of PTs to hear and they will be excited to hear those physiotherapists specifically researching the connections and associations between pain and nutrition.

It feels like it goes a bit beyond the scope of our profession or what we are used to be doing in our profession. Throughout our talk, it will become very clear that it’s something that we cannot take apart from what we are doing. We have to consider it. Physical activity is one of the core businesses we do with our patients. We will probably talk about it later on. You cannot set physical activity apart from nutrition, especially if people are obese or overweight. It has so much impact on general health and pain. You have to consider it.

A physiotherapist is such an overlap. If you have that skillset where you can educate and counsel on physical exercise, we do that very well as physios but if we can bring a little bit more than nutrition into it, then we can help with either treating a specific condition like chronic pain or the general health and wellness that we look to promote in our patients, which is important. Tell us about why this particular perspective? Why does obesity hurt?

We all know that overweight and obesity are very prevalent in general in the population. It has a massive impact on our general health. It is related to so many chronic, diabetes, and cardiovascular diseases. It has an impact. It’s a very modern, problematic disease. We see that in people with chronic pain, the prevalence rates are even higher. In fibromyalgia, 80% of patients are overweight or obese. Apart from the fact that it has so much impact on your general health, we also see that it has an impact on pain levels. Not only from the specific biomechanical loads. It’s logical. The more weight you put on the body, the more physical load there is on the body.

It seems quite reasonable that that’s related to pain. It goes much broader than only those biomechanical loads received. There is also some link with inflammatory aspects. We know that fat mass as such can become dysfunctional. It can release some pro-inflammatory cytokines. It can add to the systemic inflammatory profile, which is also linked to chronic pain. Systemic inflammation has a role in chronic pain. In that way, it’s very clear to see that something is going on. Overweight and obesity do add a more fundamental basis to chronic pain.

It’s not only seen in reasoning that we make. In humans, if they are overweight or obese and haven’t had a reduction in abdominal fat, we see that the systemic markers of inflammation will also reduce, which is very good but it’s also linked to a decrease in pain levels. Not only in weight-bearing joints. It’s a more systemic overall reduction in pain levels. It goes further than the biomechanical load for sure.

There are a lot of things that I want to start to go into a little more detail so people can take away some great things back to either their clinic or research lab. There’s an association between overweight, obesity, and pain that’s clear. There are BMI categories. As someone’s BMI increases, does pain necessarily increase in a suit?

I’m not aware of any research that answers that question. I can imagine also from the lowest perspective that indeed the higher the load, the higher the pain. From the more inflammatory perspective, it would make sense that the fatter mass there is, the more inflammatory markers can be found but I’m not aware of any research that specifically pinpoints that research question.

The one fat mass that we are all most concerned about is visceral adipose tissue, which is the fat mass that’s around our belly and waistline. The fatter mass we have in that area, typically the worst health outcomes are. Your research is pointing toward chronic pain. Adipose tissues produce adipokines, which are inflammatory cytokines, which increase other inflammatory cytokines throughout the body. Should a physical therapist start to look at one potential BMI and waist circumference? Is there a role for us to look at C-reactive protein or other basic inflammatory markers and blood work to get a full picture of what the patient is experiencing?

The first step would be BMI, waist circumference, especially go further than BMI alone because we all know that it doesn’t make that much sense to only look at BMI from an individual perspective. Blood biomarkers would give you a lot of information. It might not be that specific, though. If a CRP is raised, it can be linked to so many other aspects. I’m not sure if the cost would benefit the means. I would rather say that it would be good to look at body composition.

At the university, we have this very high technology scans to look at body composition but in clinical practice, you can use a bioimpedance scale, which will already give you some information about fat mass, fat distribution, the ratio between lean body mass and fat mass. That would be quite easy to implement in clinical practice. It’s probably easier than blood biomarkers.

Are these the easy things we can do in practice to screen for?


What about the gut microbiome? There is so much talk. The NIH has millions of dollars poured into research looking at the impact of the gut microbiome, the genetic factors and how it impacts our human health. Is there a role in that concerning chronic pain?

Yes. We talked about the load, inflammatory markers and fat mass but indeed, research is especially focused on animal research at the moment, also with the link with pain and obesity. There is probably something there as well that the good microbiome of obese people has probably changed. There is even some research showing that the microbiome can collect more energy from food in people who are obese. It’s probably also dysfunctional.

We also know about the gut-brain axis, which probably also makes it possible to link it to chronic pain. For example, there is some knowledge on the impact of the gut on glial activation in mice. In post-surgical, they see an increased glial activation in the mice who are obese, which shows that there is probably something there and there is also a link with inflammation. It’s very new research. It will give us a lot of information like NIH but also other grants are focusing on. It will probably give some very exciting and relevant new insights in the future.

You mentioned dysbiosis, which is a shift in what one would identify as a healthy microbiome to a dysfunctional one.

I don’t remember the exact names of all the bacteria but indeed there becomes a disbalance and overactivation of certain bacteria in the gut that normally in a healthy gut would not have to show such activity.

The research on the gut microbiome is most prevalent. Looking at conditions like general obesity or diabetes has shown different types of bacteria like Firmicutes and Bacteroides change in composition. Chronic pain, we are learning. There are a couple of studies out there about fibromyalgia specifically but we need more data on CRPS, low back pain, and all the different chronic pain syndrome. It is exciting to watch that data develop.

You and I are clinicians. We are talking about weight reduction and obesity. We both know it’s an important topic. It’s also a very sensitive topic for people, not only struggling with chronic pain but being overweight also. Clinicians will access this interview and they will start to talk to their patients about this. How do we start to open up and unfold this conversation in a way that doesn’t stigmatize someone and in a way that we are not saying obesity is the exact cause of your pain but it’s a component? How do we start to do that in a compassionate way for people who have been struggling?

HPP 256 | Pain And Obesity
Throughout your therapy with your patient, your therapeutic alliance will grow. There will be much more comfort and confidence from both sides.


I’m also struggling when I’m talking about this topic because I want to support body positivity and the whole movement around it but we cannot go around the fact that being overweight and obese have a lot of negative aspects as well. It’s always best to not focus only on weight, not just for the patient and the perspective of the patient but in general, we need to consider chronic pain from a broad perspective, not only the biopsychosocial perspective but also the lifestyle perspective.

In that way, it’s very logical to consider. For example, I would assess physical activity and sedentary behavior, and then the weight would be somewhere there. I would consider stress and sleep. Like this, the patient feels that the pain is being looked at from different perspectives or viewpoints. The weight is only one part of it. It does not put the focus on it directly. As physiotherapists, we are all very well aware of communication. We also have this feeling of how to communicate with the patient and feel which aspects might be a bit sensitive.

Throughout your therapy with your patient, your therapeutic alliance will grow. There will be much more comfort and confidence from both sides. That will open up possibilities to discuss weight, diet and nutrition. Since we see the patient so often on a regular basis for 30 minutes, at least in Belgium, in some countries even longer, that gives a lot of opportunities to open up the discussion. We have so much more possibilities to communicate and discuss with our patients and other health professionals. We are very well-placed to at least try to find a way to discuss it.

There is tremendous opportunity there for physiotherapists and other professionals who are working with this patient population for some time. I’m noticing that a fair amount of clinical decision-making has to happen here as a physiotherapist. As we are acutely aware of the biopsychosocial approach to pain, it’s like, “What aspect is most important?” Even in our conversation, you are talking about obesity being an inflammatory condition, which it is. That data is clear. That inflammation has an impact on systemic pain.

It also has an impact on neuroinflammation so inflammation in the nervous system. Pain neuroscience education has spread the message that inflammation isn’t necessary for chronic pain. With chronic pain, there is no inflammation so to speak. We have to balance this. Inflammation is unnecessary but there are people who struggle with inflammatory components that are significant and we have to figure out clinically, “What am I targeting first?”

In general, chronic pain is so complex. I can imagine that many clinicians are struggling very well. We all know about pain neuroscience education. In the trial that I’m conducting on overweight and obesity, I’m also giving those patients first pain neuroscience education. In any patient, you need to individualize the content of education you are given and it should also be more related to the patient’s case. For example, if a patient has sleep problems, you can also integrate the sleep problems within the education. The same applies to overweight and obesity. You can moderate the education you are giving to make sure that what fits the story is well-aligned.That’s the flexibility that pain neuroscience education gives that you can adapt. You have to maybe explain everything very much into the real details to the patient. In the education we are giving, we use a lot of metaphors. We do explain what is happening neurophysiologically but in a very understandable way, a way that someone who is not medically schooled explains what you’re saying. In that way, it is also possible to include the information on overweight and obesity even if you see that your patient is not open to neurobiology. In the story, you can use the easiest way to explain the impact of overweight and obesity, which is load and will be so easily understandable for everyone.

The load is easy for people to understand versus neuroinflammation. The suggestion of contextualizing pain education for the patient is important. It doesn’t become a broad stroke where you’re saying, “How do I adapt this important psycho information for this particular patient and what they’re struggling with?” That’s important. As a physiotherapist, how do we begin to implement weight management into clinical practice? It’s something that’s not so common but it’s becoming more common and people are aware of it.

If you want to embrace the complexity of chronic pain, you have no choice but to include all kinds of lifestyle factors. Firstly, you need to assess your patient. We have to include an assessment of body composition, body weight, specifically on the diets and nutritional aspects. Next to that is the energy balance behavior perspective. You cannot look at nutrition alone. You also have to consider physical activity because weight is very easily said by what you consume and use as energy. We have to consider physical activity and sedentary behavior.

In this way, you get a complete picture of your patient. Diet can be easily assessed using a food frequency questionnaire or food diary. It can even be done online. It’s something the patient can do in advance. You don’t have to spend too much time with the patient on that assessment in your first contact moment. The same for physical activity and sedentary behavior. Although we do see a lot of over-reporting of physical activity when you use a questionnaire. We have to be a bit careful when using only questioning for that aspect.

As soon as you have all the information, we will first start again by educating the patients. Firstly, on the link between pain and diet, the specific aspects of diet that can influence pain, overweight, obesity, and physical activity on pain to make sure that the patient understands the importance of all those aspects. Next, the patient should also know what a healthy diet is and where the differences lie between a healthy diet and the diet they have. That’s quite easy to use a food diary for that.

If the patient notes down very well what they’re eating, after some small education, they can screen for it themselves. They can look for behavior that should be changed. If they have an example of a healthy diet next, they can try to make the changes themselves with you as a coach. For a healthy diet, there are always national guidelines available that we can check as physios. The EAT-Lancet Commission has also published a very nice perspective on a healthy, sustainable diet from a more global perspective. There are a lot of information available. Lastly, if we consider weight management, there are two very important aspects to the diet, reduce calorie intake or make it healthier. Next to that is physical activity to increase the usage of calories and then physical activity. It’s not only a component that is important for weight management but it’s also a very important component of chronic pain management. The physical activity aspect is the one linking chronic pain management to weight management.

As professionals, we see there are this three-level of the physiologic bases behind this. There’s the biomechanical load, changes in the gut microbiome, and neuroinflammation. We have that science and we can use that to support what we are doing. We can use it as part of pain neuroscience education. When it comes to the actual treatment, we are going to ask the patient to make sure that this is something they want.

We ask, assess, use BMI, food frequency questionnaire and start the conversation. There are so many ways to look at nutrition. Physical activity is something we understand as PTs and know how to dive into. There are so many good educational opportunities for us to talk about exercise and physical activity, as well as diet and nutrition. Those two subjects alone can keep you busy for a whole year with the patient.

There are a lot of information you can give your patient. I’m also conducting a trial where I do weight management combined with chronic pain management for people with chronic low back pain and overweight or obesity. While composing the trial, I had the same reflection and thought, “This is too much to consider.” I made parts of the program online to track what the patient is doing on their own. When they come to clinical practice, we can have some feedback moments. I can take a coaching role. Most of it, the patient is doing alone, especially gathering the information because that’s something that they can do on their own.

With their specific questions, issues, barriers they are experiencing, you as a coach or a physio can help the patients. This asks a lot of independence and activity from the patients but it’s not very unlogical to consider that approach because not only for the dietary intervention but also for the physical activity intervention. It’s behavioral change and you do need an active and involved patient, a patient who wants to change to make that happen. From that perspective, it’s quite logical to put a lot in the hands of the patients.

When we look at studies on either diet, exercise alone or combined, there can be very long programs. There’s a randomized controlled trial on obesity where it’s a year-long program. That’s a long program but they get a tremendous amount of change from that. The important take-home for clinicians is to know that with 5 or 10 minutes, which we would identify as brief interventions, you can still change someone’s behavior and change either their eating or exercise pattern in substantial and impactful ways.

From the behavioral perspective, in those studies, it’s not uncommon to use a very long approach where they see a patient for over a year. That’s feasible in clinical practice that you would start seeing the patient in the beginning on a more regular basis, and then organize some booster sessions because when we look at the stages of behavioral change, when you are in the maintenance phase, there is always a chance on relapse. In that way, it’s quite logical to have some sessions with your physio to check how things are going and keep the patients closer for a longer time to ensure that the behavioral changes are maintained.

Oftentimes, interview researchers conduct an eight-week trial and that ends there. When you are in clinical practice, you realize people need a lot more support and need it for a longer time. The idea of twice a week for eight weeks of physiotherapy is wonderful but the relationship doesn’t necessarily end then. We can continue to monitor people. There are ways to monitor people remotely with technology, which is a useful place for all of us, both patients and practitioners.

There are a lot of opportunities to do it and we can think out of the box there. It’s good to guide the patient for a longer time. Not only when we are talking about diets but in general, chronic pain patients could benefit from that.

HPP 256 | Pain And Obesity
It would also be beneficial if you could work in a multidisciplinary way where a lot of professionals are working together for one patient.


We have been talking a lot about nutrition as a PT/physiotherapist. In the United States, nutrition is part of our scope of practice. More and more PTs are using nutrition. We live in a big world and the physiotherapy profession is different in different countries and geographic zones. What’s your recommendation to countries where physiotherapists look at this as out of their scope or, “We can’t do this. We’re not licensed to do this?” How are you starting to break down some of those barriers?

That’s something that a lot of people will run into, not only from a general perspective but also from individuals that feel they don’t have enough background knowledge. From an individual perspective, I would advise you to educate yourself. There are a lot of information available, national and international guidelines. That’s something you can do. From the lifestyle perspective of chronic pain, you cannot set aside nutrition. You cannot only focus on physical activities. You would have to assess it at least.

If you feel the case is too complex or goes beyond your knowledge, referral to specialized care is needed. It would also be beneficial if you could work in a multidisciplinary way where a lot of professionals are working together for one patient, not only to include a dietician but within the biopsychosocial perspective to work together with a psychologist that would also be very beneficial.

If you don’t have those options, if you can only work in a multidisciplinary way with your patients, it would be almost unethical not to give at least some advice on diets to make sure, especially in obese and overweight patients. If you educate yourself, there is so much information available. You could give some general advice to your patient at least on a healthy diet without going too much into details if you don’t feel comfortable doing it or if you feel that you’re at the boundaries of your knowledge.

There are national guidelines in most countries. Sometimes the national guidelines are a little bit different. I have looked at many different national guidelines on nutrition. You did mention the EAT-Lancet, which is important. Tell us what EAT-Lancet is. What is their general nutrition approach? It’s important to note that nutrition does have an impact on the individual, community, society, environment and our globe.

That’s the nice thing about EAT-Lancet. It’s a commission with a lot of experts on the nutritional diet on general health. They all work together to give more international guidelines on a healthy diet, not only for the individual but also a sustainable diet, which makes a lot of sense with the current society. The diet that they propose would be fine for all kinds of countries.If you don’t have national guidelines or don’t feel like they are sufficient, you can always look at their reports, which are also freely available. The main focus of the diet is plant-based diets. It focuses mainly on nutrition from plant-based origins. There is still some room for animal-based products but very small. The main component is plant-based. This involves fibers, fruits and vegetables.

It’s similar to a Mediterranean-based diet where it’s mostly plant-based at least five servings of fruits and vegetables. Nuts and seeds a few times a week. Red meat is sparingly probably once a week, maybe twice.

Avoiding empty calories is also an important one there.

It’s such an important topic. Avoiding processed foods, added sugar, empty calories is a big deal in nutrition. It’s a nice global way to look at nutrition. It’s sustainable. There are some environmental and economic factors there as well that people are concerned about. When you start to talk about nutrition, you hear things like, “I don’t eat meat because I don’t think it’s sustainable or don’t feel it’s ethical.” Those are important considerations when you start to work on nutrition. Anneleen, it has been great speaking to you. What’s next for you? What do you think is missing from the literature based on nutrition and chronic pain or the topic we have been talking about? It’s a big topic.

There are so many topics that I’m considering for future research. I’m conducting a trial on weight reduction in obese people also suffering from chronic low back pain. In that trial, we mainly use patient-reported outcomes. I’m also thinking about including more fundamental outcomes in the next trials like inflammatory markers. Something about the good microbiome because some very interesting things are going on at our university related to the gut microbiome. It’s not linked to chronic pain but I hope to maybe ally there.

There is also the big world of nutrition and epigenetics. Maybe there is also something we can do in the future related to chronic pain. I haven’t been doing anything specifically but I do believe that there is something to say about the triangle of diet, sleep and pain. Sleep influences the brain. We do know that but we also see that people who don’t sleep well make poor choices in nutrition. It’s a very nice opportunity to link all those three things together. I have a lot of things I want to do in the future.

It’s true that when people change their diet, they oftentimes sleep better. We are going to be looking out for your work because it’s interesting work. As physiotherapists, we have been waiting for this work to see more about diet and nutrition, and how it impacts all the different types of conditions. We see as physiotherapists that chronic pain is high on the list. Tell us how we can follow you and keep together on your work.

You can check the website of our research group, which is PainInMotion.be. From the research group, we also have many social media channels. You can find us on Facebook, Instagram and Twitter. You can also find me on Twitter using @AnneleenM_. That’s the way to follow me.

Everyone can go there and check out the Pain in Motion group. They have great information and wonderful researchers who are doing great work like Anneleen. I want to thank all of you for joining us and reading this important topic of Obesity Hurts. Make sure you share this episode with your friends, family and colleagues who are interested in the intersection between weight reduction and chronic pain management. I will see you next time.  

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About Anneleen Malfliet

Anneleen Malfliet is an assistant professor and postdoctoral researcher at the Vrije Universiteit Brussel. She is also a member of the Pain in Motion international research group. Her research and clinical interest go out to chronic pain with a special interest in chronic spinal pain, pain rehabilitation, central sensitization, nutrition and diet.
At the age of 30, Anneleen had (co-)authored >45 peer-reviewed papers in high-impact journals like JAMA Neurology and Physical Therapy Journal (33% as first author, 22% as senior author). She is cited >800 times (h-index = 15).



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