August 7, 2012

Nutritional biochemistry

What does lower back pain have in common with low carb eating?

Read Time 8 minutes

Strange question, huh? Before you get too excited, I’m not about to tell you that a low carbohydrate diet is a remedy for back pain.  Instead, I am going to explain a remarkably parallel experience I’ve had. I never made the connection until this week when a reader asked an unrelated question about lower back pain.

The best, worst experience of my life

As my third year of medical school was winding down, and I was just about to embark on a bold fourth year curriculum of back-to-back-to-back-to-back surgical sub-internships, I was on top of the world.  I was 27 years old, living in Palo Alto, California with my best friends, I had a wonderful girlfriend, I was working hard to prepare for my application to a surgical residency, and I still found time to work out like a wannabe Olympian.  What more could I ask for?

One sunny, June afternoon I got out of the pool after a good workout and felt a very strange pain in my lower back.  After riding my bike a few hundred yards to the weight room, it wasn’t getting better.  Actually, it was getting worse.  So bad, in fact, I did something I’d never done before – I decided to skip my workout and pedal home.

I iced my back, took some ibuprofen, and went to bed.  The next morning I woke up only to realize I literally could not get out of bed.  After struggling for some time I had to call my roommate to get me out of bed and help me to the bathroom.  I called my chief resident and apologized that I would not be able to come in to the hospital that day, and assured him I’d be fine the next day.  But I wasn’t.  Nor was I fine the day after or the day after.

A few days later I managed to limp my way into the hospital for rounds and with the help of the residents and nurses who were kind enough to give me intramuscular injections of a potent drug called toradol, I was able to survive, just barely.  The pain had gotten worse over the week and I was unable to sleep in any position except lying face down over a counter in an “L” shape.  But the worst was yet to come.

Within a few more days, not only was my back hurting, but I was also experiencing profound sensory pain in my left leg and left foot.  I realize this may sound hyperbolic, but I am not exaggerating at all when I say it felt like the skin was being torn off the bottom of my left foot.  The only way I could sleep was to tie my left foot in a plastic bag of ice to numb it and take 100 mg of Benadryl (enough to put a horse to sleep).  When the ice melted, I would wake up in pain and need to repeat the routine.

Within about 3 weeks of this back and leg pain, I was starting to worry that something very serious was going on.  I’d had a backache or two before, and in one case it even took a week to resolve.  But this was very different.  One night, when the pain was so bad I couldn’t mask it with any cocktail of drugs I finally relented and went to the ER.  After a thorough exam, the physician sent me to the MRI scanner (for those of you reading this outside of the U.S., it must sound crazy to think that a patient could have a MRI scan so quickly).

The MRI showed not only a large herniation of my L5-S1 disk (a bulging of the disk between my L5 and S1 vertebrae), but it also showed a free fragment of broken disk sitting directly on the S1 nerve root.  While the large bulging disk was likely the cause of my back pain, the free fragment pressing one of the largest nerves in my body was undoubtedly the culprit in my leg and foot pain.

The next morning I was taken to surgery by a (supposedly) talented and reputable neurosurgeon.  I was actually very relieved and excited, despite never having undergone surgery or general anesthesia before.  I was told this surgery would fix the problem immediately.  But it didn’t.  In fact, as it turned out, this was the beginning of a long, sordid ordeal, albeit with a positive take-away that is the point of my story.

I woke up from surgery and immediately realized the pain was still there, in my left foot.  Worse yet, I had trouble moving my right foot, which was completely fine before surgery.  Over the next few days it became clear I had developed something called a foot drop on my right side.  I would later learn the surgeon had operated on the wrong side and likely injured the nerve on the right side. Things had gone from bad to worse.

Compounding this, the surgeon who operated on me refused to believe my description of what I was experiencing and was convinced I was just being “soft” for complaining of persistent pain and a new problem.  After 2 weeks of further deterioration — and only when another physician examined me, and herself ordered another MRI — did my surgeon agree I still had a significant surgical lesion.

That night I went back to the operating room and, this time, operating on the correct side, the surgeon removed a 4-centimeter fragment of disc from my spinal canal that was still compressing my S1 nerve root (below).

back pathology specimen

The next three months proved to be what I would later describe as the “best, worst” experience of my life – an assertion I still maintain nearly 15 years later.  For a number of other reasons and complications I suffered that I won’t detail here for sake of time and space, I became completely debilitated after developing another complication called a facet arthropathy.  So much so that my mother flew to California to stay with me, just to feed me and drive me around to endless doctor appointments.

My dream of becoming a surgeon had quickly vanished along with any athletic aspirations I once had.  I worried whether I’d ever walk again and had begun to accept the fact that I may be addicted to pain killers for the rest of my life. [For anyone familiar with such medications, I was taking about 200 mg of oxycodone per day – about 40 times what a “normal” person would take following a painful dental procedure.]

Things I once took for granted – walking, being able to lean over the sink while brushing my teeth, sneezing without feeling like my kidneys were being ripped out – became distant and fading memories.

Fortunately, with the help of some remarkable doctors (which included several more trips to the operating room), kinesiologists, and physical therapists, I would slowly learn to move again without pain.  I had to train as hard and deliberately for this as I had for every other athletic endeavor I’d ever poured myself into.

I experienced firsthand what narcotic withdrawal is like and the depression that accompanies it.  I experienced firsthand what an arrogant surgeon can do to a patient.  I learned more about medicine in that year than at any other time in my medical training.

As a postscript to this story, I eventually made a remarkable recovery and was able to begin my surgical residency a year later with minimal pain.  Today my back is stronger than it was before this incident. Except for the few people I have shared this story with (until now), no one would ever know what I went through.  I move through the world like someone with a perfectly healthy and strong lower back.

I also gained a profound understanding of pain and addiction, which became one of the most valuable lessons I carried with me through my brief medical career.  It allowed me to understand what a heroin-addicted person goes through, when viewed through the lens of my own experience with the strongest painkillers.

A few years later I would become close friends with Drs. Marty Makary and Peter Pronovost when our paths crossed during my residency at Johns Hopkins.  Marty and Peter have become two of the biggest pioneers of patient safety and the avoidance of medical mistakes.  My story became one of many presented in Marty’s soon-to-be-released book, Unaccountable.

Years later, based on my experience and research I did while overcoming this injury, I gave many talks on the treatment and prevention of lower back injuries and have become a minor expert on the subject.  If anyone is interested, here is a link to one of my presentations (slides only, no video/audio).

What does this have to do with a low carb diet?

Today, when I pick up anything, whether it be a cotton ball or a piece of paper, I do it with my legs, not my back.  When I lean over the sink to brush my teeth, I support the weight of my torso with my arm.  When I get out of a car or out of bed I position myself not to torque my back.  When I need to lift a 265 pound barbeque out of my car, like I did a few months ago, my lower back is never under strain.  How did I learn to do this?  Through a very deliberate and long process of adaptation.  I had to re-learn how to move, how to sit, how to lift, how to sneeze.  Were it not for the long and painful road to recovery I endured, I may have never learned these things.

Many people who suffer back injuries never really recover.  When they do “recover” from one injury, the rate of relapse is very high.  While no two cases are identical, much of the reason for this lies in 2 factors:

  1. The injured person does not learn how to modify their behavior to avoid re-injury.
  2. The injured person does not take the necessary steps to strengthen and rehabilitate their back.

“Curing” a back injury is not a temporary thing or something that just happens because we wish it to be so. It is a very deliberate lifestyle change.  Over time, as we form habits, we can go from consciously thinking through every necessary behavior change – something easy to do when we are in pain – to a place where the behavior is more automatic. But this takes time.

In many ways, transitioning to a low carbohydrate diet is similar.  Consider the figure below.

4 stages

Just like with behaviors that predispose us to lower back injury, most people go through life just eating on autopilot, but eating the wrong things, the “default” things.  They graze in a reactionary manner without any understanding of how what they eat impacts their body.  They are eating in an unconsciously incorrect manner.

Many people learn that what they are eating is actually not ideal and not predisposing them to maximum health.  They move into a place of consciously incorrect behavior.  They realize drinking a Coke with fries and a candy bar is not good for them, despite still eating them.  Some of these people go one step further and actually make corrections – removing sugar and simple carbohydrates from their diet, for example – but doing so requires great effort and deliberate action.  They are now in the realm of consciously correct eating.

This is the place where most people get stuck.  It hurts.  It’s hard to do.  They get frustrated.  Maybe even ridiculed by friends and family.  Most turn back to consciously incorrect eating with brief periods of re-visiting consciously correct eating.  Hence, only a few people make their way into the final stage of unconsciously correct eating, just as only a few people with serious back injuries ever make it into a state of unconsciously correct movement.


Because it takes a lot of time and a lot of effort.  It’s different for everyone, but I know for me it took almost 2 years to get to the point of unconsciously correct eating.  I had spent 36 years mindlessly eating the wrong way, just as I had spent 27 years mindlessly moving the wrong way before injuring my back.

Sixty years ago it was quite easy to default into the correct way of eating because we were mostly surrounded by foods that supported such eating.  But, our food environment has changed dramatically and today’s default eating (e.g., high amounts of sugar, grains, highly refined carbohydrates) puts most of us – about 60 or 70% of us – at serious risk of metabolic disease.  One day, I believe, the work of NuSI and others will fix this problem, and through the elucidation of unambiguous science allow us to create a food environment that supports easier (and more affordable) default eating of the right foods.   However, until then we have to go through these stages.

If you find yourself feeling frustrated at how difficult it is to get from consciously eating well to unconsciously eating well, remember that you are on a journey.  If you are consistent and patient, if you remind yourself that you are embarking on a journey to change your life and not a short-term fix to look good in a bathing suit next month, you will embrace the right mindset to find the ‘sweet’ spot of unconsciously correct eating.

I will be the first to admit that this is not easy.  But, if you’re reading this, you’re already down the path and you’ll be better able to help the next person who struggles through the 4 stages of transition because you’ve experienced it yourself.

Photo by Meta Zahren on Unsplash

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.


  1. Hi,
    So what was the diet that you followed? If you could answer it would help me as well as I am suffering with back pain.

    • All that for that little little little bit on low carb. Wait… did he even mention keto… I can’t remember…

  2. First, I want to thank you for the tremendous amount of work and information you have created here on your site. I find it truly amazing that the typical recommendations for healthy eating could be so wrong for so many people. Since I discovered your site a couple weeks ago, I have been telling everyone I know about it and passing on some of the information I’ve gleaned from it. (I enjoyed the few articles I read so much, I am going back to the beginning and reading every post!) I am an engineer, so I especially appreciate your commitment to the scientific method and teaching causation vs. correlation. Everything you write really resonates with me.

    I began my own journey of eating correctly 3+ months ago, though I started more along the lines of a high protein, moderate-low fat, and low carb (zero sugar) diet. Even though I have had early success, I’ve learned after reading some of your articles this isn’t exactly a recipe for nutritional ketosis – probably too much protein to achieve ketosis. Now, I’m beginning a transition to incorporate more fats, less protein, and even fewer carbs. I admit, it is still difficult to get around the mindset that has been drilled into me all these 30-some past years that fats are bad for you and give you heart disease. Luckily, I had my annual physical with bloodwork done just before the start of my journey, so I have a baseline to make a comparison soon (albeit imperfect, VAP). I am very excited to see my results and am also looking into an economical DEXA scan for comparison to the results given by my bioimpedance weight scale.

    I also want to thank you for this particular article. I herniated the same disc you did (L5-S1) at age 28 (~6 months after original posting date of this article). I was completely immobile for 8 weeks while on large doses of oxycodone and cyclobenzaprine to manage my back/leg/foot pain. To top it off, my wife and I had a 15-month old daughter and I couldn’t help or be the father I wanted to be. Add emotional pain to physical pain and pharmaceutical depressants…I was not in good shape to say the least.

    The doctors began treatment with corticosteroid injections. I was told I could have them no more frequently than every 2 weeks, and a maximum of 4 in the span of a year. After 3 injections with no improvement, the next step was a microdiscectomy. In my case, they performed the surgery properly and I had immediate pain relief. Three years later, I still have numbness on the outside of my left foot and toes, but I don’t notice it much – certainly not debilitating. I can’t imagine what you went through. The most frightening part for me was that following my recovery period when I was no longer on pain medication, I recognized I was going through physical withdrawal. Constant shaking of my hands, irritability, what felt like constant anxiety, episodes of sweating, etc. It was a real eye-opener into how easy it is to get addicted to these drugs. Now, I finally understand how we become addicted to sugar.

    Like you, I’ve gone from the unconsciously incorrect to consciously correct in my body mechanics, core strength training etc. I am now at consciously (almost)-correct in my diet and hope to achieve the unconscious habits for lifelong health. I may not find that a truly ketogenic diet is best for me, but certainly a low-carb/zero sugar diet is where I want to start and adjust the protein/fat ratio to what I find is best for me.

    Once again, thank you for this wonderful resource you have put together and sharing your story.

  3. This is such a great read! I’m hooked on clonazepa 10mg each night. As I can not sleep due to my back pain. Sadly a year old Work Injury I’ve yet to be treated for. I can not handle pain pills as they give me migraines. My doctor is switching me to Ambien. For some reason I keep pulling away from it each time I go to take it. Interesting that a side effect is pain.

    I’m so sorry for what you had to go through. As much pain that I’ve been in and abuse by the system, I’ve yet to go through what you have. Thank you so much for writing about your experience. I will be checking out more of your information regarding the back, proper posture, and low to no carbs


  4. Hi Peter
    Thanks for sharing.

    I’m a 46 year old mom to 3 boys, ages 13, 11, and 11.
    I bent over one day to pick up toys to lower my treadmill.
    I have never been the same. The pain was so excruciating, I finally gave in and went to primary care. She sent me to ortho.
    I have seen pain management doctor, orthopedic surgeon, therapists.
    Had countless epidurals, RFA’s, facet blocks, lumbar fusion, spinal stimulator implanted twice, the leads came undone.
    Still in bad pain.
    I’ve gained over 50 lbs from being inactive. I try to walk but fail miserably, even with just down the street.
    I’m trying to eat better, portion control, decide if I’m hungry or bored by saying to myself… If you’re hungry.. Eat vegetables, instead of crap.
    Sometimes it works.
    Depression has sunk hard.
    I’m on so many meds..
    900 mg Gabapentin TID
    Baclofen 10 mg TID
    Motrin 800mg. TID
    Tylenol in between motrin
    Cymbalta 90mg in the am
    Vicodin 7.5/325 BID
    Xanax for occasional panic attacks.

    Kids ask me when I’m going to be better so I can do this and that.
    I have no answer.. Except.. I hope soon.
    But.. I know that isn’t true.

    I just had another steroid injection Friday. Go back in 2 months for another.

    I’m so tired. I don’t know what to do sometimes. No one can seem to help me.

    Anyway… Working on my diet to try and lose weight, hoping that will help some. With summer coming.. Pool goes up soon… About the only exercise I can do is walking in water.

    Somewhat relieved to know I’m not the only one going through this hell.

    Thanks for reading.

    • Linda, I’m really sorry to hear this. I wish I had something to offer other than sympathy. I hope you find a great PT who can condition you back to health. Many cases of back pain do not require surgery, as I did.

    • Hi Linda,
      I really hope you are feeling much better now. Why don’t you try the Gokhale Method? It has changed my life.
      Take care.

  5. I’m so glad I came across this!

    6 years ago I herniated discs L4-5 and L5-S1. Agony! I found the work of Dr Bookspan who says you can fix most back disc problems with correct posture and exercise. She was right – 2 weeks later I was in the gym, 2 more I was back on a tennis court. I learnt like you to hold my posture correctly without even thinking about it. 6 years on and I’ve never had so much as a twinge.

    I’m now on the road with LCHF eating and keep falling off the wagon. Thanks to your post I’m now going to approach it like I did my back issue safe in the knowledge it will eventually be something I do unconsciously – I’ve just got to work to get there.

  6. Just came back here to take a look at the lower back exercises again. Great post and presentation, thanks for sharing!

    **Q: What exercises do you recommend for strengthening lateral movement?**

    (You mentioned the gluteus medius, tensor fasciae latae and vastus medialis on Tim Ferriss’s show).

  7. Recently I have to study sitting for hours at one sport. I later discovered I experience pains getting out of the bed (back pain). But once I could stand the pain appears to reduce. I can walk as if nothing happened until I go to sit. then I will experience pains. What do I do? Thanks

  8. Actually I was googling reasons why back pain can increase during the low carb dieting but instead stumbled across your article.

    My doctor placed me back on this diet due to on going high blood pressure. Every two weeks my blood pressure and food log is recorded by the practitioner. I’ve learned to drink lots of water, broth, and eat heathy fats etc. to reduce the ” ketosis/ low carb flu” symptoms.

    This morning I work up with lower back pain which was one of the reasons why I had my IUD removed a week before restarting this diet. 5 hrs ago I wAt first I thought it could be due to cramping which is common after removal among other things. I’ve come across some articles stating a low carb diet can cause back pain due for loss of minerals, dehydration, ect, and was research for more information.

    Thank you for sharing your inspiring story.

    • I went on low carb/Keto diet, to lose ten pounds. Now within a few days on the Keto diet, I could not keep water down I tried to drink water and automatically it was sprouted out like I was a fountain. My throat was swollen. I had lower back pain, and first time EVER in life I had sciatica the pain was out of this world I had dark circles under my eyes. First stop my dad drove me to an MD they found nothing wrong second stop chiropractor and masseuse found nothing I had an adjustment . Third doctor was a Naturopathic/ Chinese medicine doctor . He asked me my diet and my blood type He told me my throat and stomach were inflamed and that stomach inflammation was causing my back pain, and sciatica. I lost 15 pounds because I was in so much pain that I could hardly eat. He put me on gentle soup diet with bone broth and certain vegetables , and warm tea’s some herbs. Within a few days I was all back to normal . He told me simply this ” Everything isn’t for everyone” Everyone blood types and , genetics, DNA are not the same.

  9. Interesting read. Came across your post while searching a link between back pain and a low carb diet. I’ll explain my story (sorry for my english).

    Until 5 years ago I worked out at gym, went out running and surfing very regularly. I was very fit and active. Suddenly, for no apparent reason, a lower back pain came to my life. It would be always there and get worse after any exercise, even a 10 minutes walk. Xrays and MRI’s did never show anything which had my doctors puzzled. No amount of stretching, visits to physiotherapists or even chiropractors helped. After this pain started, my life became more and more sedentary. I was becoming depressed.

    Few months ago, after watching my growing belly in the mirror, I decided to start a keto diet to lose some weight. So I did cut out as many carbs as possible and after few weeks I realized that not only my belly was getting smaller but pain was gone. It’s been 4 months already pain-free. I just can’t understand what’s the connection between a carb-free diet and pain.

    I’m not any type of keto evangelist, neither I try to convince anyone to change their habits. I just felt the need to share my story here. More often than not I crave for carbs but I’m afraid to eat them and experience the pain again!

    • Thanks for replying to me. Yes 58 is “young” but I wanted to do other things and working in the British NHS is “difficult”. I am keen on sports and although not the most energetic thing I play a lot of golf and have reduced my handicap to better than Scratch. It’s something I always wanted to do.
      I’ve posted a few other comments/queries and it would be great if you or one of your team has the time to answer them. Ian

      • Oh hell that explains it…in the US we retire..usually in our late 60s if we work in healthcare. UNless you’re like me, a lab tech…then you work forEVER. I have a 80 year old coworker! (Not kidding!)

  10. Very painful for anyone to spend a young age with such pain. Thankfully we understand the importance of what should be our intake for a healthy life. Thank you for sharing your experience. Helps a lot.

  11. I am on my way home from a week stay at the hospital. The 3rd hospital. The first sent me home twice when I said the pain in my foot and leg was like the skin was being ripped off the bone and by back I couldn’t explain the pain was so bad I was hysterical. They checked for blood clots. Twice. Refused even a CT Scan. I went to another hospital and finally sent to a major hospital. Because of my size, I couldn’t have a MRI but they did a CTTest with Dye? Still don’t understand. I have 2 discs laying on nerves. They gave me a epidural and told me to Pray that works. The Dr said 5 pounds a day till I lose 100 pounds then he will do surgery. I am praying that this epidural holds. I still can’t feel my foot

  12. I injured my back in June 2018 and i while it was initially super painful (had to call an ambulance as couldn’t move), after a week of pain relief I was back to work albeit a bit slowly. It never really got fully better with osteopath & accupuncture, anyway over a year later i finally got at MRI which showed a protuding disc at L5S1, but as I’m not in a lot of pain, its more niggly and achy, so surgery isn’t likely. I found this site while googling “protruding disc & the keto diet”to see if I could see a link between the anti inflammatory benefits of keto helping backpain. I read you story & feel I need to stengthen my back & learn to do things differently too. Things that worry be are sneezing, making the bed, getting items out of the grocery trolley. I live in fear of my back giving out on me as it feels week. Any suggestions on who to see or how to start to this process?

  13. Help, I have back pain after an early Dec. 2019 fall on a black iced hill. I am also 35 pounds overweight and must change to try and prevent back surgery. I want to be healthier and more fit. I am 73 years old with a dilemma of growing more frail, while maintaining the motivation to change. Knowledge and direction are what I lack.

  14. Dr. Attia, just came across this article, and as I read it began reliving my almost exact same experience. L5-S1root insult, supposedly from disk degeneration. Was on a five mile run and heading up a steep incline when the pain hit me like a bolt of lighting. I haven’t felt pain that severe in a while. It reached peak intensity the next day while I was hosting a meeting in the US Embassy in London; the meeting was cut short. Went to a specialist on Harley Street and got an MRI. They discovered the culprit and placed me on the schedule for Discectomy. This particular surgeon did not have laser tech for the procedure, so it was going to be manual. I had a month’s time between diagnosis and planned operation. Thankfully, the intense pain went away but a new symptom arose. My muscles associated with the L5-S1dermatome atrophied to negligible strength. My right gluteus muscles, right calf, and the bottom right half of my (right) foot lost sensation, tone and strength. My colleagues joked and told me I was half-assing everything during that time. I did not experience a full foot drop, I was still able to hike during our weekend trip to Iceland, thank God. But I had a limp. I’ve had a full wrist drop before and I know how hard it is to rehabilitate. Can’t imagine the work you put in for the foot drop. It has been six years, I still have little sensation in my dermatome, but I have all my strength back. I do have permanent pelvic tilt from the degenerated disk, and if I do not wear my shoe insert for a day, my QL and psoas group will overcompensate and result in a few days of back pain/stiffness. Just as you stated, I had to retrain my everyday body mechanics and sleeping positions to protect my back. I have also focused on my keeping my erectors, glutes, hams strong in order to support my back. I had no idea how critical engaging your core muscles during lifting also protected you from back injury.

    I do have a question, can you tell us if the L5-S1 issue was result of disk degeneration, or from an isolated incident. Very interested in this story and can attest to the level of pain you experienced. Not a picnic at all. Thank you for sharing!

  15. Thank you for posting this, very relatable! Long time listener to your work, keep it up!

    In November 2020 after an injury, I couldn’t roll out of bed. I went for an MRI and CT, turned out I had bilateral pars breaks at L4/L5 that were separated by 1cm, along with a collapsed disc, and two bulging discs. This lead me to have Spondylolithesis and in turn surgery. Unfortunately I had to have two surgeries because the first left me with little to no function of my right leg, and excruciating pain. I’m now left with metal Implants however was able to avoid a fusion! I’m now 4 months post surgery and in zero pain thanks to my diet and rehabilitation, mostly learned from yourself. I have listened to you speak a lot about the importance of deadlifting, please could you help me with how to safely start this, and how it could potentially help. From the UK, thanks Peter!

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